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A    MANUAL   OF    MEDICINE 


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Infective    Micro-organisms. 


A 

/VNUAL  OF  MEDICINE 


EDITED   BY 


W.  H.  ALLCHIN,  M.D.  (loxND.),  F.R.C.P.,  F.R.S.E. 

SENIOR  PHYSICIAN  AND  LECTURER  ON   CLINICAL  MEDICINE,  WESTMINSTER 

HOSPITAL,   EXAMINER   IN    MEDICINE   IN   THE   UNIVERSITY   OF 

LONDON,  AND   TO    THE   MEDICAL   DEPARTMENT 

OF   THE   ROYAL   NA"\-\' 


VOL.     I 

GENERAL   DISEASES 

DISEASES  EXCITED  BY  ATMOSPHERIC  INFLUENCES 
THE  INFECTIONS 


THE   MACMILLAN    COMPANY 

LONDON:   MACMILLAN  &  CO.,  Ltd. 
1900 

All  rights  reserved 


Copyright,  1900, 
By  the  MACMILLAN   COMPANY. 


Nottoooli  ^resB 

J.  S.  CushiDg  &  Co.  —  Berwick  &  Smith 
Norwood  Mass.  U.S.A. 


TO 

THE    MEMORY 

OF 
MY   TEACHER 

^ir  Milliam  lettitsr,  §art.,  (S.Cl. 

M.D.,    F.R.C.P.,    F.K.S. 

PHYSICIAN    IN    ORDINARY   TO    H.M.    THE    QUEEN,    AND 

TO    H.R.H.    THE    PRINCE    OF    WALES 

PHYSICIAN   TO    UNIVERSITY    COLLEGE    HOSPITAL 


W.   H.  A. 


PLATE    I. 


Fig.  I. 


Streptococcus  Pyogenes  in  Pus  from  case  of  Empyema.     Fixed  by  Wet  Method. 
Stained  with  Eosin  Alum  and  Methylene  Blue,      x  looo  diams. 


Fig.  2. 

Section  of  Diphtheria  Membrane.     Bacillus  Dipbtherise.      Stained  by  Gram's 
Method  and  Saffranin.       x  looo  diams. 


Fig.  3. 

Scraping  from  Septic  Pleurisy,  showing  Eraenkel's  Pneumococci  with 
Capsules.      Stained  by  Muir's  Method.      x  1000  diams. 


Fig.  4. 

Bacillus  of  Typhoid  Fever  showing  Elagella.     Muir's  Stain  for  Flagella. 
X  1000  diams. 


Fig.  5. 

Bacillus  of  Bubonic  Plague.     48  hours'  Agar  Culture  ;  Flagella  seen.     Stained  by 
Muir's  Method.      x  1000  diams. 


Fig.  6. 

Actinomyces  in  Liver  Abscess,  showing  Filaments  and  Clubs.      Stained  by 
Gram's  Method,  Saffranin  and  Eosin.       X  lOOO  diams, 


PLATE    II. 


Fig.  7. 

Koch's  Spirillum  of  Cholera.     12  hours' Agar  Culture  ;  Flagella.     Muir's  stain 
for  Flagella.      x  1000  diams. 

Fig.  8. 

Bacillus  Tetani  in  scraping  from  wound  (Hand)  from  case  of  Tetanus.     Fixed  by 
Muir's  Method.     Stained  with  Eosin  and  Methylene  Blue. 

Fig.  9. 

Skin  from  case  of  Leprosy.     Bacilli  stained  by  Ziehl  Neelsen  Method,  with 
Methylene  Blue  for  contrast  stain,      x  1000  diams. 


Fig.  10. 

Bacillus  Tuberculosis  in  Lung  in  Acute  Tubercular  Broncho-pneumonia. 
Stained  by  Ziehl  Neelsen  Method.      x  1000  diams. 


Fig.  II. 

Bacillus  Anthracis  (Spores).     3  days'  Agar  Culture.     Stained  by  Ziehl  Neelsen 
Method — Fuchsine  and  Methylene  Blue  Method,      x  1000  diams. 

Fig.  12. 

Amoebic  Dysentery.     Amoebae  in  wall  of  Abscess  of  Liver.     From  Specimen 

kindly  supplied  by  Prof  Greenfield.      Fixed  by  Corrosive  Sublimate 

Method.     Stained  by  Benda  Method,      x  1000  diams. 


CONTENTS 


Contributors 

Introduction 

General  Diseases 

Diseases  #ue  to  Atmospheric  I 

The  Infections 

Fever 

Boil  and  Carbuncle 

Erysipelas 

Saprremia,  Septicaemia,  and  Pyaemia 

Infective  Endocarditis 

Gonorrhoeal  Infection 

Typhoid  Fever    . 

Mediterranean  Fever 

Cholera 

Plague     . 

Relapsing  Fever 

Yellow  Fever 

Weil's  Disease     . 

Anthrax 

Tetanus 

Diphtheria 

Epidemic  Pneumonia 

Infective  Meningitis 

Influenza 

Glanders 

Tuberculosis 

Leprosy 

Mycoses 


24 
50 
59 
62 
68 

77 
82 
86 
no 
1x6 
128 
139 
143 
149 

152 
156 

163 
178 
182 
202 
217 
220 
235 
243 


vin 


MANUAL  OF  MEDICINE 


Typhus  Fever 

Measles 

Rotheln 

Scarlet  Fever 

Acute  and  Subacute  Rheumatism 

Chicken-pox 

Smallpox 

Vaccinia 

Mumps 

Whooping-Cough 

Dengue 

Beri-Beri 

Epidemic  Dropsy 

Oriental  Sore 

Verrugas 

Frambcesia 

Syphilis 

Rabies 

Foot  and  Mouth  Disease 

Mixed  Infections 

Dysentery 

Malaria 

Hremoglobinuric  Fever 

Kala-azar 


Index 


PAGE 

252 
259 

269 

274 

291 
310 
316 
328 

337 
340 
350 

353 
360 
362 
364 
365 
367 
389 
396 
398 
402 
416 
429 
433 

437 


PLATES 

Plates  i  and  2  :  Infective  Micro-organisms 

Temperature  Curve  in  a  Case  of  Typhoid  Fever — Two  Relapses- 
Recovery  ...... 


Facing  Title 


CONTRIBUTORS 


John  Rose  Bradford,  M.  D.  ,  D.  Sc. ,  F.  R.  C.  P. ,  F.  R.  S.     Physician  to  University 
College  Hospital ;  Professor  Superintendent  of  the  Brown  Institution. 
{Mycoses,  Rabies.) 

Frederick  Foord  Caiger,  M.D.,  B.S.,  M.R.C.P.,  D.P.H.  Medical  Super- 
intendent and  Lecturer  on  Infectious  Diseases,  South-Western  Fever  Hospital, 
Stockwell. 

{Diphtheria,  Measles,  Rotheln,  Scarlet  Fever,  Varicella. ) 

James  Cantlie,  M.B.,  CM.,  F.R.C.S.,  D.P.H.  Lecturer,  School  of  Tropical 
Medicine,  London ;  Surgeon,  Seaman's  Hospital  Society ;  Consulting 
Surgeon,  Alice  Memorial  Hospital,  Hong-Kong. 

{Cholera,  Plague,  Leprosy,  Dengue,  Beri-Beri,  Epidemic  Dropsy,   Oriental 
Sore,  Dysentary,  Malaria,  HcBmoglobinuric  Fever,  Kala-Azar.) 

William  Cayley,  M.D.,  F.R.C.P.  Senior  Physician  to  the  Middlesex 
Hospital. 

( Typhoid  Fever,  Typhus  Fever. ) 

Sydney  Monckton  Copeman,  M.D.,  F.R.C.P.,  D.P.H.     Medical  Inspector 
to  H.  M.  Local  Government  Board  ;  Lecturer  on  Public  Health  in  the  West- 
minster Hospital  Medical  School. 
( Variola,  Vaccinia. ) 

John  Alfred  Coutts,  M.B.,  F.R.C.P.  Physician  to  the  East  London 
Hospital  for  Children. 

( Tuberculosis,  Inhe^-ited  Syphilis. ) 

Bertrand  Edward  Dawson,  M.D.,  B.Sc,  M.R.C.P.  Assistant  Physician  to 
the  London  Hospital ;  Pathologist,  Royal  Hospital  for  Diseases  of  the 
Chest. 

{Influenza. ) 

Thomas  Colcott  Fox,  M.B.,  F.R.C.P.     Physician  to  the  Skin  Department, 
Westminster  Hospital. 
( Verrugas,  Fravibcesia. ) 

William  Wilberforce  Goodall,  M.D.  Medical  Superintendent,  Eastern 
Hospital,  Homerton. 

{Mumps,  Mixed  Infections. ) 


X  MANUAL  OF  MEDICINE 

Richard  Grainger  Herb,  M.D.,  F.  R.C.  P.  Secretary,  Royal  Microscopical 
Society  ;  Physician  in  charge  of  Out-Patients,  and  Lecturer  on  Forensic 
Medicine,  Westminster  Hospital. 

(Gonorr/iceal  Infection,  Epidemic  Cei'ebro-Spinal  Meningitis,  Glanders,  Foot 
and  Month  Disease. ) 

Matthew  Louis  Hughes,  L.R.C.P.,  M.R.C.S.     Capt.  R.A.M.C.  (the  late). 
{Mediterranean  Fever.) 

David  Bridge  Lees,  M.D.,  F.R.C.P.  Physician  and  Lecturer  on  Medicine, 
St.  Mary's  Hospital. 

{Acute  atid Subacute  Rheumatism.) 

William  Grant  Macpherson,  M.B.,  CM.,  D.P.H.,     Major  R.A.M.C. 
{ Yellow  Fever. ) 

Arthur  Newsholme,  M.D.,  F.R.C.P.     Medical  Officer  of  Health,  Brighton; 
Examiner  in  State  Medicine,  University  of  London. 
{Epidemic  Pneumonia. ) 

Francis  George  Penrose,  M.D.,  F.R.C.P.  Physician  to  St.  George's 
Hospital. 

( Whooping-  Cough. ) 

George  Newton  Pitt,  M.D.,  F.R.C.P.  Physician  and  Lecturer  on  Pathologj', 
Guy's  Hospital. 

{Anthrax,  Tetanus.) 

George  Frederick  Still,  M.D.,  M.R.C.P.  Assistant  Physician  for  Diseases 
of  Children,  King's  College  Hospital ;  Assistant  Physician  to  the  Hospital 
for  Sick  Children,  Great  Ormond  Street. 

{Posterior  Basic  Meningitis,  Suppurative  Meningitis. ) 

Alfred  Herbert  Tubby,  M.D.,  F.R.C.S.  Surgeon  to  the  Westminster 
Hospital. 

{Boil  and  Carbuncle,  Acquired  Syphilis. ) 

John  Wickenford  Washbourn,  M.D.,  F.  R.C.P.  Physician  to  Guy's  Hospital 
and  Lecturer  in  the  Medical  School ;  Physician  to  the  London  Fever 
Hospital. 

{Erysipelas,  Infective  Endocarditis,  Relapsing  Fever,  Weils  Disease.) 

William  Hale  White,  M.D.,  F.R.C.P.     Physician  and  Lecturer  on  Medicine, 
Guy's  Hospital. 
{Fever. ) 

German  Sims  Woodhead,  M.D.,  F.R.C.P.,  Ed.  Professor  of  Pathology  in  the 
University  of  Cambridge. 

( The  Infections,  Sapramia,  Septiccemia,  atid  Pycemia. ) 

and 
The  Editor. 

{Diseases  due  to  Atmospheric  Itifluences. ) 


A    MANUAL   OF    MEDICINE 


INTRODUCTION 

The  term  "  Medicine  "  is  generally  understood  to  denote  the  study 
of  disease  in  the  various  directions  which  engage  the  attention  of 
the  scientific  investigator  and  the  practical  physician.  Therein  is 
included  the  inquiry  into  those  precedent  conditions  commonly 
known  as  the  causes  which  determine  departures  from  health 
—  the  subject  of  (f//(?/(907/  the  perversions  of  structure,  macroscopic 
and  microscopic,  which  the  tissues  and  organs  exhibit  as  the 
result  of  these  recognised  or  assumed  causes  —  the  department  of 
morbid  anatomy ;  the  mode  of  action  of  disease  processes  and  their 
effects  on  the  various  organs  and  functions  of  the  body,  the  forms 
of  malnutrition,  general  and  local  —  the  subject  matter  oi pathology 
in  its  restricted  sense  ;^  the  signs  and  symptoms  of  structural  and 
functional  defects  ;  the  manifestations  of  disease  as  appearing  in  the 
living,  —  the  so-called  semeiology  or  more  commonly  clmical  medicine, 
in  which  also  is  comprised  the  modes  of  examination  of  the  patient, 
the  detection  of  the  symptoms,  and  the  drawing  of  inferences  from 
the  evidence  so  obtained,  in  short  the  formation  of  a  diagfiosis  and 
naming  the  disease,  as  well  as  the  expression  of  a  forecast  or  antici- 
pation of  the  probable  course  and  ending  of  the  special  malady 
under  consideration  —  the.  prognosis  ;  and  finally  there  is  that  branch 
of  the  subject  denominated  therapeutics  which  deals  with  the  //-<?«/■- 
;;/(?;z/ of  disease,  by  diet,  by  general  hygiene,  and  by  drugs,  M'ith  the 
art  of  its  application  ;  to  which  also  may  be  added  the  prevention  of 
disease  and  the  care  of  the  public  health.  Extensive  as  this  range 
of  subject  matter  is,  it  is  far  from  all  that  is  really  involved.  The 
study  of  disease  presupposes  a  knowledge  of  the  normal,  which  is 

1  Pathology  in  its  literal  significance  denotes  the  study  of  disease  in  all  its 
aspects. 

VOL.  I  B 


2  MANUAL   OF   MEDICINE 

a  necessary  preliminary  to  the  recognition  of  variations  from  the 
standard  of  health,  and  for  the  full  pursuit  of  this  wide  scope  of 
investigation  there  is  scarcely  any  department  of  natural  science, 
from  geology  and  meteorology  to  botany  and  zoology,  physics  and 
chemistry,  which  is  not  in  some  degree  drawn  upon  to  contribute  to 
the  elucidation  of  the  complex  problems  concerned. 

It  might  naturally  be  supposed  that  in  a  work  professing  to  deal 
with  the  natural  history  of  disease  in  its  various  aspects  and  many 
forms,  that  some  explanation  of  what  is  meant  by  "  disease  "  would 
be  attempted,  and  for  the  purpose  of  giving  some  coherence  to  the 
descriptions  which  are  to  follow,  it  is  desirable  that  the  attempt 
should  be  made,  premising  that  any  definition  is  but  provisional 
and  subject  to  correction  as  greater  precision  of  knowledge  is 
attained,  and  is  only  a  working  hypothesis  for  the  time  being. 

Health  and  disease  are  correlative  terms  expressive  of  certain 
structural  and  functional  states  of  the  body  and  its  workings,  dis- 
tinguished the  one  from  the  other  by  no  clearly  recognisable  Hne  of 
separation,  and  neither  of  them  conforming  to  one  fixed  and  definite 
type.  The  standard  of  bodily  health  is  at  present  incapable  of 
accurate  definition  ;  its  borderland,  where  it  merges  into  disease, 
cannot  be  mapped  out,  whether  it  be  in  the  direction  of  structural 
changes  or  of  functional  manifestations,  but  it  is  certain  that  the 
limits  of  this  standard  are  wide,  and  that  there  are  many  ways  of 
being  well,  many  types  of  health.  Marked  variations  from  this  ill- 
defined  condition  constitute  disease,  the  commencements  and 
slighter  forms  of  which  can  seldom  be  formulated.  In  these  modes 
of  living  three  factors  are  assumed  :  the  bodily  structure,  its  functional 
activities,  and  the  environment ;  life,  whether  normal  or  morbid,  is 
the  resultant  of  their  interaction.  By  observation  or  by  experience 
there  is  recognised  a  certain  range  of  structure,  of  function,  and  of 
environment,  as  associated  with  what  it  is  agreed  to  regard  as  healthy 
life,  characterised  for  the  most  part  by  a  freedom  from  pain  or  dis- 
comfort, departures  from  which  are  considered  as  disease.  The 
notion  of  disease  implies  no  new  element,  but  simply  some  per- 
version of  the  factors  that  together  make  up  health. 

The  fundamental  conceptions  of  structure  and  function  —  what 
the  body  is  and  what  it  does  —  are  inseparable.  We  only  know  the 
one  through  the  other ;  we  only  recognise  the  material  or  structure 
by  the  properties  which  it  manifests,  and  conversely  the  properties 
are  inconceivable  apart  from  the  material  through  which  they  are 
rendered  sensible. 

The  connotation  of  "  structure  "  is  not  to  be  restricted  to  the 


INTRODUCTION  3 

results  of  anatomical  investigation,  whether  gross  or  minute,  whether 
of  the  fully-formed  organ  and  tissues  or  of  these  in  the  course  of 
their  development  and  differentiation.  The  actual  disposition  and 
arrangement  of  the  component  materials  of  the  body  is  not  bounded 
by  what  the  microscope  discloses.  There  is  a  further  stage  in  the 
inquiry  into  what  a  Hving  (as  also  a  non-living)  body  or  any  part 
of  such  body  really  is,  known  as  its  chemical  composition  and 
molecular  constitution,  and  when  that  is  reached  the  structure  of  an 
object  in  its  fullest  sense  may  be  regarded  as  known.  "  Chemical 
structure,"  which  implies  not  only  the  chemical  elements  and  pro- 
portions thereof  of  which  a  substance  is  composed,  but  also  the 
arrangement  of  the  atoms  of  these  elements  in  the  molecules,  and 
the  relations  they  bear  to  one  another,  is  the  third  and  final  stage  of 
structure,  the  first  and  second  being  gross  and  minute  anatomy 
respectively.  This  last  stage  is  still  within  the  realm  of  theory, 
but  the  hypotheses  which  are  current  are  among  the  fundamental 
conceptions  upon  which  all  our  knowledge  of  the  material  world  is 
built. 

Inseparable  from  the  idea  of  structure  are  the  properties  by 
which  it  is  recognised.  Such  are  weight,  hardness  or  softness, 
flexibility  or  rigidity,  elasticity,  permeability  and  the  like,  all  de- 
pendent on  the  character  of  the  relationships  existing  between  the 
ultimate  constituent  molecules  of  the  material.  These  and  others 
are  AtwovcMX'AX.Q.^  physical propei-fies,  and  are  possessed  by  all  matter, 
whether  living  or  not.  Certain  substances,  however,  over  and 
above  these  quahties,  manifest  certain  specific  properties,  in  virtue 
of  which  they  are  called  living,  and  similarly  it  is  generally  assumed 
that  these  properties  are  the  outcome  of  some  special  molecular 
structure.  These  peculiarly  vital  characteristics  may  be  grouped 
thus:  (1)  Those  which  may  be  collectively  termed  "irritability," 
that  is  the  various  forms  of  response  to  the  application  of  stimuli 
(often  of  external  origin)  which  we  recognise  as  muscular  con- 
traction, nervous  energy,  glandular  secretion,  together  with  the 
power  of  multiplication  and  perpetuation  of  the  race  by  fission, 
gemmation,  etc.  (2)  Those  comprehended  in  the  processes  —  other 
than  purely  chemical  —  by  which  the  living  material  increases  in 
bulk  and  maintains  its  structural  and  functional  integrity  by  the 
conversion  of  food  into  its  own  substance  —  the  nutritive  or  meta- 
bolic processes.  (3)  Within  a  variable  range,  living  matter  has,  as 
one  of  its  most  significant  peculiarities,  the  power  of  adapting  itself 
to  variations  of  the  external  conditions  subject  to  which  it  exists. 
Within  certain  Hmits  of  temperature,  barometric  pressure,  quality  of 


4  Manual  of  medicine 

food,  etc.,  living  things  may  adjust  themselves,  beyond  which,  how- 
ever, they  succumb.  A  highly  specialised  phase  of  this  resisting 
power  of  the  living  tissues  is  known  as  immunity.  (4)  Lastly,  all 
living  things,  sooner  or  later,  cease  to  display  these  vital  character- 
istics and  die. 

Much  difference  of  opinion  has  prevailed  as  to  the  nature  of 
these  "  vital  "  phenomena.  Formerly  it  was  held  that  life  and  the 
manifestations  of  organism  generally  were  due  to  a  special  "  vital 
force  "  or  "  principle,"  fundamentally  different  from  physico-chemical 
forces,  and  were  not  to  be  investigated  by  physico-chemical  methods. 
During  the  last  fifty  years,  however,  this  vitahstic  theory  has  gradu- 
ally been  displaced  by  a  reference  of  the  manifestations  of  life  to 
physico-chemical  standards,  with  the  important  result  that  very 
many  of  the  phenomena  of  the  living  organism  are  understood  and 
explained  "  by  comparison  with  their  physical  counterparts  "  (Burdon 
Sanderson).  Extensive  and  fruitful  as  the  consequences  of  this  pro- 
cedure have  been,  there  still  remain  certain  living  manifestations 
which  are  not  considered  as  being  capable  of  either  investigation  or 
explanation  by  these  means,  which  it  is  further  alleged  are  quite 
inapplicable.  A  new  vitahsm  has  been  recently  promulgated,  which, 
accepting  to  the  full  all  that  physico-chemical  methods  have  done 
in  explaining  many  of  the  living  activities,  aims  at  investigating 
those  which  the  physico-chemical  physiologist  tends  to  regard  as 
unknowable,  by  the  extension  to  the  study  of  living  things  of  the 
principle  which,  in  the  hands  of  the  morphologists,  has  elucidated  so 
many  problems  of  structure,  viz.  "  that  each  part  of  an  organism  is 
determined  as  regards  its  mode  of  existence  by  its  relation  to  other 
parts,"  which  is  "just  as  much  a  physiological  as  an  anatomical 
conception"  (J.  Haldane). 

Consistent  with  this  view  a  much  wider  and  indeed  truer 
range  of  meaning  must  be  attached  to  the  notion  of  environment 
than  that  which  restricts  it  to  the  mere  influence  of  conditions 
outside  the  body,  cUmatic,  telluric,  dietetic,  occupational,  etc.,  im- 
portant and  subtle  as  these  may  be.  The  functional  activity  of 
each  organ,  of  each  tissue,  and  of  each  cell  reacts  upon  these 
external  influences,  the  effect  of  which  is  conditioned  by  the  state 
of  the  organism  itself.  Moreover,  the  vitality  of  each  structural 
element  is  not  to  be  regarded  in  its  origin  or  its  manifestation  as 
independent  of  the  vitahty  of  other  constituents  of  the  body,  but 
rather  that  there  should  be  included  in  the  idea  of  interaction  of 
organism  and  environment,  the  mutual  effect  of  living  cells  and 
dssues  upon  each  other. 


INTRODUCTION  5 

The  notion  of  disease  embodied  in  the  foregoing  remarks  will 
show  that  it  involves  equally  a  structural  and  a  functional  side. 
Both  aspects  are  included  in  the  expression.  There  can  be  no 
structural  abnormality,  however  minute,  without  some  functional 
perversion ;  and  conversely  a  functional  imperfection  necessarily 
implies  a  structural  defect.  But  just  as  there  are  many  functional 
manifestations,  both  of  health  and  disease,  which  are  not  accom- 
panied by  any  structural  change  recognisable  by  the  means  at 
present  at  our  command,  so  many  structural  abnormalities  may  be 
found  post-mortem  without  any  functional  defect  obviously  con- 
nected therewith. 

The  conception  of  life,  whether  healthy  or  diseased,  as  the  result 
of  interaction  between  the  organism  and  its  environment,  facilitates 
the  comprehension  of  the  direction  in  which  the  so-called  causes  of 
disease  produce  their  effects.  On  the  one  hand,  the  disturbance  of 
function  may  be  clearly  due  to  faults  in  the  surrounding  conditions 
—  food,  temperature,  occupation,  etc.  —  constituting  the  acquired 
diseases.  On  the  other,  the  causation  of  the  morbid  states  is  some 
inherent  defect  due  to  imperfection  of  the  organism  as  derived  from 
the  parents  —  hereditary  diseases.  It  may  be  that  these  intrinsic  or 
extrinsic  defects  are  so  strong  as  inevitably  to  assert  themselves  and 
produce  disease,  or  it  may  be  that  neither  cause  may  be  sufficiently 
potent  to  lead  to  disease  of  itself,  requiring  for  its  efficient  action 
some  defect  in  both.  Thus  the  transmitted  Hability  or  tendency  to 
disease  may  not  assert  itself  until  the  external  conditions  have 
transgressed  the  limits  ordinarily  recognised  as  normal,  or  that  the 
latter  may  be  inoperative  until  the  resisting  powers  of  the  organism 
have  deteriorated.  It  is  a  combination  of  both  kinds  of  faults  that 
is  probably  responsible  for  most  cases  of  disease. 

So  far  the  general  nature  of  disease ;  but  the  perversions  of 
structure  and  function  known  as  the  signs  and  symptoms  of  disease 
are  found  to  occur  in  groups  with  more  or  less  constancy  and  uni- 
formity, constituting  the  various  diseases  to  which  special  names  are 
attached,  such  as  epilepsy,  typhoid  fever,  pneumonia.  Occasionally, 
however,  obscure  cases  are  met  with  which  do  not  conform  to  any 
of  the  recognised  special  diseases,  and  cannot  be  named.  When 
the  evidences  of  disease  are  primarily  or  mainly  confined  to  one 
organ  or  region,  the  malady  is  termed  local,  but  seldom  or  never  is 
the  disease  absolutely  so  restricted  ;  the  rest  of  the  body  participates 
much  or  httle  in  the  abnormal  state.  If,  however,  the  signs  and 
symptoms  are  more  generally  distributed  and  no  organ  appears  to  be 
predominantly  involved,  a  general  disease  is  said  to  exist.     Such  a 


6  MANUAL   OF    MEDICINE 

distinction,  however,  is  in  great  measure  artificial,  and,  like  the 
notion  of  separate  diseases,  is  apt  to  be  pushed  too  far  and  lead  the 
beginner  to  expect  a  definiteness  in  the  several  maladies  which  does 
not  and  cannot  exist.  The  descriptions  of  disease  in  text-books  on 
medicine  unavoidably  tend  to  favour  this  mistake,  which  bedside 
work  alone  can  avert. 

The  investigation  of  these  various  diseases  in  the  living  is 
capable  of  consideration  from  two  points  of  view.  On  the  one 
hand  may  be  taken  the  description  of  an  individual  case,  the  history 
of  the  patient  as  regards  his  family,  his  age,  occupation,  mode  of  lite, 
and  previous  illnesses,  whereby  an  estimate  may  be  formed  of  his 
personal  health-value  in  its  relation  to  the  special  ailment  from 
which  he  is  suffering  ;  the  condition  of  the  patient  might  be  set  forth, 
and  the  progress  of  the  disease  to  its  termination,  together  with  such 
treatment  as  may  have  been  followed,  and  the  effect  thereof.  Such 
a  description  would  be  one  of  the  disease  as  manifested  by  that  one 
individual.  But  it  will  be  readily  understood  that  the  disease  would 
exhibit  differences  in  its  symptoms  and  course,  and  that  in  no  two 
persons  would  it  be  exactly  alike,  any  more  than  the  normal  life  of 
the  two  would  be  identical.  From  the  consideration  of  a  large 
number  of  individual  cases,  what  might  be  termed  a  typical  or 
standard  or  mean  account  of  the  malady  might  be  prepared,  to 
which  all  cases  of  the  same  would  correspond  in  the  main,  differing 
in  detail  as  the  individuals  themselves  and  their  conditions  of  life, 
constitution,  age,  and  sex  would  differ.  There  is,  then,  besides  the 
clinical  description  applicable  to  each  separate  case,  a  general  or 
systematic  account  of  each  separate  malady  collated  from  a  study  of 
many  cases.  Such  an  account  must  necessarily,  as  knowledge 
advances  and  precision  of  observation  extends,  be  modified  from 
time  to  time,  as  the  successive  editions  of  current  text-books  testify. 
It  is  well  for  the  student  to  remember  that  the  description  of  each 
disease,  as  given  in  systematic  treatises,  rarely  corresponds  to  any  one 
case,  though  most  cases  may  be  comprehended  within  it ;  and  since 
in  the  time  at  his  disposal  it  is  impossible  for  him  to  form  for  himself 
anything  like  a  complete  account  of  the  various  forms  of  disease 
from  the  observation  of  individual  cases,  he  must  depend  on  the 
labours  of  others.  It  is  as  supplementary  to  his  clinical  work  that 
text-books  and  systematic  lectures  have  their  use. 

A  systematic  account  of  the  principles  and  practice  of  medicine 
necessitates  a  classification  of  the  various  morbid  states  which  we  are 
in  the  habit  of  regarding  as  separate  diseases.  And  with  classifi- 
cation —  nosology  —  there    at    once   enters    into    the    question    an 


INTRODUCTION  7 

artificial  disposition  of  the  various  phenomena,  which  is  constantly 
undergoing  revision,  and  at  the  best  must  be  unsatisfactory,  since 
the  material  to  be  classified  is  so  many  sided  and  so  complex  that 
no  plan,  within  our  present  knowledge,  can  effectively  arrange  the 
multitudinous  varieties  of  disease  without  the  occasional  violation 
of  any  principle  of  grouping,  whatever  it  be,  or  the  rupture  of  what 
are  apparently  the  natural  affinities  between  the  various  maladies. 
Doubtless  the  most  satisfactory  and  most  scientific  arrangement  of 
the  groups  of  phenomena  which  constitute  the  various  diseases  we 
are  familiar  with  would  be  based  upon  their  causation,  the  circum- 
stances and  conditions  that  preceded,  and,  as  we  say,  determined, 
the  departure  from  the  normal  standard  of  health.  But  our 
knowledge  of  this  standard,  and  still  more  of  the  intimate  nature 
and  mode  of  working  of  the  causes,  is  most  imperfect,  and  at 
present  quite  unfit  to  be  made  the  sole  ground  of  classification, 
the  object  of  which  after  all  is  for  convenience  of  record  and 
study,  and  at  the  best  most  imperfectly  represents  the  natural 
conditions.  Or,  consistently  with  the  preceding  conception  of 
disease,  its  varieties  might  be  primarily  grouped  according  to 
imperfections  of  the  fundamental  properties,  physico-chemical  and 
vital,  which  the  tissues  possess.  Thus  one  group  of  morbid  pro- 
cesses might  be  due  to  impaired  elasticity,  flexibility,  permeability, 
or  other  such  qualities ;  another  to  defects  in  muscular,  nervous,  or 
glandular  irritability,  whether  in  the  direction  of  excess,  of  deficiency, 
or  of  perversion ;  a  third  class  of  maladies  are  fundamentally  im- 
perfections of  the  metabolic  processes  constituting  tissue  nutrition, 
whether  on  the  constructive  side,  that  is  connected  with  the  due 
elaboration  of  the  ingesta,  or  in  respect  to  the  subsequent  tissue 
destruction  and  consequent  waste  formation  and  elimination.  An 
altered  resisting  or  adaptive  power  on  the  part  of  one  tissue  or  organ, 
or  of  the  entire  body,  characterises  a  fourth  group  of  infirmities, 
which  would  comprise  those  tissue  changes,  expressive  of  a  response 
to  an  irritant,  included  within  the  term  *'  inflammation."  And  a 
proneness  to  degeneration  and  premature  senility  or  death  is  the 
leading  feature  at  the  root  of  others.  At  present,  however,  any  such 
scheme  is  inapplicable  ;  our  knowledge  would  not  enable  an  even 
approximately  complete  classification  to  be  made,  and  for  purposes 
of  convenience  it  would  be  futile.  It  is,  nevertheless,  occasionally 
advantageous  to  contemplate  the  general  field  of  disease,  or  even  of 
individual  cases,  from  some  such  standpoint,  imperfect  though  it  be. 
No  scientific  principle  therefore  is  to  be  looked  for  in  the  plan 
here   followed.      The  old-fashioned  separation  into  "general"  and 


8  MANUAL    OF    MEDICINE 

"local"  diseases  has  taken  too  firm  a  hold  to  be  lightly  discarded 
in  a  student's  manual,  and  opinion  is  not  yet  prepared  for  a  plan  of 
dealing  with  the  subject  which  would  abolish  the  time-honoured 
category  of  diseases  of  the  various  systems  of  organs,  and  substituting 
a  grouping  under  their  causal  conditions,  or  as  manifestations  of 
general  pathological  states,  rather  than  under  the  organs  which  in 
many  cases,  but  not  always,  are  mainly  or  primarily  affected.  But 
it  may  be  anticipated  that  some  such  arrangement  will  have  to  be 
followed  in  the  future. 

It  is  obviously  impossible  within  the  limits  of  a  single  work  to 
treat  of  all  of  the  many  sides  of  this  comprehensive  subject,  and  at 
once  some  limitation  has  to  be  imposed.  In  the  following  pages 
will  be  found  an  account  of  the  various  forms  of  disease,  more 
especially  from  the  point  of  view  of  their  clinical  manifestations  and 
treatment.  The  subjects  of  etiology  and  morbid  anatomy  are  briefly 
summarised,  and  for  further  knowledge  of  these  aspects  of  disease 
reference  must  be  made  elsewhere.  The  aim  has  been  to  present 
such  a  picture  of  the  several  maladies  as  will  conform  to  the  appear- 
ances detected  at  the  bedside,  and  enable  the  observer  rationally  to 
administer  such  treatment  as  our  art  affords. 

The  Editor. 


GENERAL    DISEASES 

By  general  diseases  —  a  phrase  of  no  very  precise  definition  —  is 
meant  those  maladies  in  which  the  entire  body  is  more  or  less 
concerned,  with  no  preponderance  of  symptoms  in  one  region,  or 
where  any  local  manifestations  are  quite  disproportionate  or  secondary 
to  the  widespread  disturbance  of  function.  They  are  either,  for  the 
most  part,  associated  with  fever  and  acute  in  character,  or  are  pro- 
found affections  of  the  general  nutrition  tending  to  a  chronic  course 
and  a  fatal  termination. 

A  grouping  of  the  diseases  comprehended  within  this  category 
is  mainly  based  on  grounds  of  convenience  and  on  no  definite 
scientific  principle.  As  a  provisional  arrangement  the  following  plan 
is  adopted  :  — 

I.  OF  EXTRINSIC  CAUSATION. 

1.  DISEASES  EXCITED  BY  ATMOSPHERIC  IXELUEXCES. 

2.  DISEASES     CAUSED    BY     THE     IXVASIOX     OE    LIVIXG 
ORGANISMS. 

r  *  Ectophyta 
1  e.g.    Tinea 

Vegetable-^     Entophyta 

I  e.g.  Bacilli.     Actinomycosis 

Entozoa 
I  e.g.  Plasmodium  MalaricB 

Animal  -  Intestinal  and  other  worms 

\  *Ectozoa 
^  eg.  Pediculi 

3.  DISEASES  DETERMINED  B  Y POISONS  IXTROD  UCED  IXTO 
THE  BODY  AS  SUCH. 

e.g.  mineral  and  food  poisons,  serpent  venom,     (intoxications.) 

II.  OP  INTRINSIC  ORIGIN. 

1.  PRIMARY  PERVERSIOXS    OF  GENERAL   NUTRITION. 

2.  DISEASES    OF  THE   BLOOD. 

*  Will  be  treated  of  under  Diseases  of  the  Skin. 


Infective  diseases. 


DISEASES  EXCITED  BY  ATMOSPHERIC  INFLUENCES 

The  influence  of  the  various  factors  of  the  environment,  such  as 
temperature,  light,  moisture,  barometric  pressure,  electrical  states, 
etc.,  collectively  denominated  atmosphere,  in  the  production  of 
disease,  is  undoubted.  Oftenest,  perhaps,  they  act  by  so  impair- 
ing the  resisting  power  of  the  organism  as  to  permit  other  morbific 
agents  producing  their  effect ;  sometimes,  however,  they  appear  to 
be  mainly,  if  not  entirely,  the  excitant  of  definite  morbid  states  or 
even  of  death.  Co-existing  as  they  do,  it  is  difficult  to  appreciate  the 
individual  share  each  may  take  in  the  causation  of  disease,  their 
effect  in  this  direction  being  more  probably  a  combined  one. 

I.  Temperature 

{a)  Heat.  —  To  excessive  heat,  whether  of  the  sun  directly  or 
in  the  shade,  or  artificially  produced,  are  attributed  very  various 
conditions,  to  which  the  terms  "  heat-stroke,"  "  sun-stroke "  (in- 
solation) ,  or  "  heat-apoplexy  "  are  indififerently  applied.  Considerable 
difference  exists  in  the  resisting  power  of  individuals  and  of  races, 
and  habitual  exposure  usually  confers  increased  tolerance.  The  ill 
effects  of  heat  are  much  intensified  by  atmospheric  moisture  —  such 
as  occurs  in  the  stoke-holes  of  steamships  —  whereby  the  loss  of 
heat  from  the  skin  is  much  diminished  and  the  regulation  of  the 
body  temperature  consequently  interfered  with.  Other  favouring 
conditions  are  unsuitable  clothing,  great  physical  exertion,  alcoholism, 
heart  disease,  or  other  enfeebled  states  of  health.  When  the  exposure 
takes  place  in  a  confined  space  or  crowded  room,  the  vitiated  air 
doubtless  contributes  to  the  result. 

Symptoms,  —  The  chief  clinical  distinction  among  cases  of 
heat-stroke  depends  upon  whether  the  body  temperature  of  the 
patient  is  or  is  not  elevated.  Sometimes,  however,  in  the  milder 
non-febrile  forms  pyrexia  may  develop. 


DISEASES  EXCITED  BY  ATMOSPHERIC  INFLUENCES     ii 

The  leading  features  of  the  apyretic  cases  are  extreme  exhaustion 
and  tendency  to  syncope,  a  subnormal  temperature  and  partial 
collapse,  with  vomiting,  dilated  pupils,  and  small,  quick  pulse. 
Milder  degrees  of  these  conditions  are  famiUar  to  all,  from  the 
pleasurable  sense  of  lassitude  to  the  more  severe  states.  In  some 
there  are  superadded  dyspncea  and  failing  respiration ;  such  cases, 
being  usually  more  sudden  in  onset  and  more  fatal,  are  among  those 
frequently  termed  "  heat  apoplexy." 

To  those  cases  of  heat-  or  sun-stroke  which  are  marked  by  hyper- 
pyrexia the  names  "  thermic  fever  "  or  "  siriasis  "  are  specially  applied. 
All  degrees  of  suddenness  of  attack  are  met  with,  from  those  who 
are  struck  down  and  die  within  a  few  minutes  or  hours  to  those  in 
whom  for  several  days  before  the  dangerous  symptoms  appear  there 
is  general  weakness,  headache,  nausea,  drowsiness,  and  frequent  and 
copious  micturition. 

"  Generally,"  says  Dr.  Sambon,  whose  admirably  graphic  de- 
scription I  quote  almost  verbatim  {Brit.  Med.  Joiirn.  1898,  i.  p.  744), 
"patients  are  seized  with  severe  headache,  an  alarming  sense  of 
general  oppression  or  exhaustion,  or  difficulty  in  breathing,  and  a 
distressing  burning  in  the  eyes,  associated  with  vertigo  and  chroma- 
topsia  (surrounding  objects  appearing  of  uniform  colour,  usually  red, 
blue,  or  purple).  The  skin  is  dry  and  intensely  hot;  the  patient  is 
pale  and  excessively  thirsty.  The  pulse  is  full,  rapid,  and  bound- 
ing; respiration  is  hurried  and  oppressed.  The  temperature  rises 
suddenly  to  107°  or  108°,  or  even  to  112°  or  higher.  Vomiting  is 
very  common,  and  may  be  a  special  feature  at  the  outset ;  purging  is, 
in  severe  cases,  almost  always  present,  the  motions  being  watery  and 
colourless.  The  skin  and  breath  have  a  peculiar  mousy  odour. 
Cramps  in  the  calves  of  the  legs  or  in  the  muscles  of  the  back,  some- 
times amounting,  it  is  said,  to  opisthotonos.  A  maculo-papular 
eruption  has  been  described  as  of  occasional  occurrence,  but  it  is 
not  characteristic.  Insensibility  soon  sets  in,  from  which  at  first 
the  patient  may  be  roused,  but  which  soon  deepens  into  profound 
coma.  Convulsive  twitchings  of  the  facial  muscles,  or  arms,  or  even 
general  convulsions  may  be  present ;  but  frequently  the  patient  lies 
motionless  from  the  commencement  to  the  termination  of  the  attack. 
The  reflexes  are  diminished  or  abolished.  The  urine  is  scanty  and 
often  suppressed ;  it  usually  contains  traces  of  albumen,  a  few  hyahne 
or  granular  casts  and  blood  corpuscles.  The  breathing  becomes  almost 
entirely  diaphragmatic ;  the  patient  grinds  his  teeth  and  moans  loudly 
at  each  expiration,  loud  rales  and  rhonchi  being  audible  over  the  chest, 
with  cyanosis  of  the  face.     The  eyes  are  fixed  and  turned  slightly 


12  MANUAL    OF    MEDICINE 

upwards ;  the  conjunctivae  are  excessively  congested,  and  the  pupils 
are  contracted  to  mere  pin  points  and  do  not  react  to  light.  After 
a  time  convulsions  and  vomiting  cease  and  the  patient  passes  into  a 
state  of  low  muttering  delirium  ;  the  skin,  still  hot,  becomes  clammy ; 
the  heart's  action  becomes  more  rapid,  weaker,  and  irregular,  and 
the  respiration  slower  and  stertorous,  or  of  the  Cheyne-Stokes'  type, 
with  loud,  mucous,  tracheal  rattling.  Frothy  mucus,  often  blood- 
stained, is  ejected  by  mouth  and  nostrils,  and  the  patient  dies  from 
asphyxia.  In  favourable  cases  the  temperature  falls,  the  pupils 
relax,  and  the  patient  regains  consciousness ;  the  respiration  im- 
proves and  the  pulse-rate  declines ;  not  uncommonly  there  is  a  dis- 
charge of  urine,  after  which  sleep  follows.  Termination  is  usually 
by  crisis,  and  although  the  prostration  is  extreme,  con\-alescence  is 
rapid."  The  duration  of  the  symptoms  varies  from  a  few  hours  in 
the  fatal  cases  to  one  or  occasionally  a  couple  of  days.  Relapses  are 
frequent,  setting  in  after  complete  defervescence  has  occurred. 

Prognosis. —  "  Taking  one  type  of  heat-stroke  with  another," 
says  Dr.  Manson,  "  the  case  mortality  among  English  troops  in 
India  is  about  one  in  four."  The  highest  death-rate  is  to  be  found 
among  cases  of  siriasis.  ]Most  attacks  of  heat  exhaustion  or  syncope 
recover,  if  treatment  be  applied.  The  asphyxial  variety  of  the  latter 
is  certainly  more  fatal. 

Sequelae.  —  Although  recovery  from  a  severe  attack  may  take 
place,  it  is  commonly  the  case  that  the  patient's  health  continues 
more  or  less  impaired,  and  often  for  a  long  time.  Various  nervous 
diseases,  such  as  headache,  sometimes  severe  and  persistent  epileptic 
seizures,  and  even  insanity  with  suicidal  or  homicidal  tendency  or 
mania  have  been  known  to  follow  sun-stroke,  and  loss  of  memory, 
insomnia,  and  generally  deteriorated  mental  power  are  frequent.  A 
remarkable  intolerance  of  heat  is  commonly  exhibited  by  individuals 
who  have  once  been  attacked  (see//.  Tropical  Med.,  Nov.  1898). 

Post-mortem  appearances. — These  may  be  of  the  slightest 
and  are  rarely  distinctive.  The  temperature  may  continue  to  rise 
after  death.  Rigor  mortis  supervenes  soon,  lasts  but  a  short  time, 
and  putrefaction  rapidly  follows.  The  blood  remains  fluid,  is  acid 
in  reactipn,  and  clots  but  little ;  considerable  post-mortem  staining  of 
the  skin  and  other  tissues  is  to  be  seen,  and  extreme  engorgement  of 
the  viscera,  especially  the  lungs  and  whole  venous  system,  with 
sanguineous  effusions  into  the  venous  cavities.  A  marked  rigidity 
of  the  ventricles  is  described  as  existing  for  a  short  time  after  deathc 
The  substance  of  the  brain  and  spinal  cord  is  not  unduly  congested, 
but  the  ganglion  cells  are  said  to  exhibit  an  acute  parenchymatous 


DISEASES  EXCITED  BY  ATMOSPHERIC  INFLUENXES     13 

degeneration ;  the  meninges  are  usually  hypersemic  and  appearances 
of  commencing  meningitis  have  been  noted.  The  liver  and  renal 
cells  show  granular  degeneration. 

Pathology. — The  patholog}'  of  these  conditions  is  uncertain, 
as  indeed  is  the  explanation  of  the  regulation  of  the  normal  body 
temperature.  A  consideration  of  the  symptoms  would  suggest  that 
the  extreme  heat,  especially  that  of  the  sun,  by  which  the  most 
severe  cases  are  caused,  exerts  an  injurious  influence  on  the 
temperature-controhing  centres,  whether  these  be  "spinal"  or 
those  which  regulate  the  loss  of  heat,  \-iz.  the  vaso-motor  and 
respiratory  centres,  and  those  which  govern  the  tissues  generally, 
more  particularly  the  muscles,  by  which  the  heat  is  produced.  But 
there  is  no  knowledge  how  such  assumed  influence  acts. 

An  explanation  of  another  kind  has  been  proposed  for  those 
cases  marked  by  hyperpyrexia.  Their  suddenness  of  onset  and  the 
general  character  of  their  course  and  symptoms,  as  well  as  the 
apparent  occurrence  of  siriasis  in  epidemics,  and  the  marked 
tolerance  that  is  exhibited  by  the  natives  and  old  residents  in  tropical 
climates,  are  features  that  bear  a  close  resemblance  to  those  mani- 
fested by  the  acute  specific  diseases,  and  Dr.  Sambon  does  not 
hesitate  to  include  siriasis  among  the  infectious  fevers.  It  may  be 
further  observed  that  it  is  by  no  means  necessarily  in  the  hottest 
times  of  the  day,  nor  in  the  direct  solar  rays,  but  rather  at  night,  that 
the  majority  of  cases  occur.  Nor  is  it  equally  prevalent  in  all  hot 
countries,  for,  according  to  Dr.  Sambon,  siriasis  is  restricted  to  low- 
lying,  sea-coast  districts  and  certain  river  valleys,  and  is  never  met 
with  much  above  an  altitude  of  600  feet  —  in  short,  that  it  is  an 
endemic  disease  dependent  upon  extreme  heat  for  its  development, 
but  not  owing  its  causation  to  that  condition. 

Treatment.  —  Much  may  be  done  in  the  way  of  prevention  by 
the  obser\'ance  of  certain  precautions,  especially  by  new-comers  in 
those  regions  where  the  hability  to  attack  is  greatest.  Avoidance  of 
exposure  to  the  sun  and  protection  of  the  head  and  neck  by  suitable 
cov-erings  are  essential,  and  scarcely  less  so  are  light,  loose,  woollen 
clothing,  and  free  ventilation  of  the  dwelling-rooms,  particularly  at 
night.  The  mode  of  living  should  be  moderate  in  all  respects  — 
a  light  diet,  a  minimum  of  alcohol,  and  no  excess  of  bodily  or  mental 
labour,  but,  if  possible,  a  midday  rest  is  most  desirable,  as  well  as 
the  encouragement  of  free  skin  action  by  cold  baths  and  simple 
drinks. 

Success  in  the  treatment  of  the  attack  largely  depends  on 
promptness  of  administration.     For  the  syncopal  and  asphyxial  forms 


14  MANUAL    OF    MEDICINE 

stimulants  must  be  given  at  once  and  freely  by  the  mouth  or 
rectum,  or  by  subcutaneous  injections  of  brandy,  ether  or  strychnine, 
as  well  as  sinapisms  to  the  neck  or  calves.  The  patient  should  be 
kept  in  the  recumbent  position  and  carefully  watched  for  several 
hours,  as  there  exists  a  tendency  to  relapse  even  in  the  milder  cases. 
It  may  be  necessary  to  apply  hot  bottles  or  even  a  hot  bath  when 
the  surface  is  very  cold. 

Inasmuch  as  one  great  danger  in  the  hyperpyrexial  attack  is 
failure  of  the  heart,  stimulation  in  these  cases  is  equally  necessary,  but 
a  valuable  and  all-important  adjunct  is  the  application  of  cold  by 
affusion,  sponging,  ice  packing  and  cradhng,  ice-water  enemata  or  cold 
baths,  by  which  the  temperature  of  the  patient  may  be  reduced. 
The  various  antipyretic  drugs,  owing  to  their  depressing  action  on  the 
heart,  are  contra-indicated.  It  is  seldom  that  bleeding  is  permissible, 
though  it  may  be  beneficial  in  the  asphyxial  forms.  Subcutaneous 
injections  of  hydrochlorate  of  quinine  (gr.  v.),  or  of  tincture  of 
digitalis  (m.  xl.),  are  recommended  by  Dr.  Manson,  but  strychnine 
should  not  be  given  owing  to  the  liability  to  convulsive  seizures. 

For  a  person  who  has  experienced  an  attack  of  siriasis  removal 
to  a  temperate  climate  is  imperative,  and  abstinence  from  alcohol 
most  desirable.  Counter-irritation  by  blisters  to  the  nape  of  the 
neck  may  be  necessary,  and  benefit  follows  a  course  of  iodide  of 
potassium  or  sodium  combined  with  bromides. 

The  effects  of  the  solar  rays  or  of  great  heat  upon  the  skin,  such 
as  sunburn,  freckles,  various  forms  of  erythema,  prickly  heat,  etc., 
will  be  referred  to  elsewhere. 

{b)  Cold.  —  As  an  etiological  factor  of  disease  this  has  long  been 
recognised,  but  it  is  certain  that  it  is  not  of  the  importance  as  a 
cause  that  was  formerly  held  —  even  as  a  contributory  circumstance 
its  influence  has  been  probably  over-estimated.  It  would  seem  that 
exposure  to  an  unduly  low  temperature  can  rarely  be  held  solely 
responsible  for  any  special  disease,  although  by  diminishing  the 
resistance  of  the  body  to  microbic  invasion,  and  perhaps  of  favouring 
the  occurrence  of  inflammation  by  vascular  disturbance,  it  may  in- 
directly become  an  exciting  cause,  largely  influenced  by  the  age,  sex, 
and  general  condition  of  the  patient.  Certain  symptoms  of  disease, 
however,  such  as  pain,  are  very  liable  to  increasingly  manifest  them- 
selves on  exposure  to  cold,  especially  if  this  be  associated  with 
dampness.  Even  the  local  affection  known  as  chilblain  appeals  to 
depend  as  much  for  its  occurrence  upon  the  state  of  the  individual 


DISEASES  EXCITED  BY  ATMOSPHERIC  INFLUENCES    15 

as  upon  cold,  but  frostbite  may  fairly  be  attributed  only  to  this 
cause,  which  may  also  directly  lead  to  death. 

The  general  effect  of  extreme  cold,  according  to  the  degree  and 
duration  of  exposure,  is  to  repress  the  vitality  until  death  occurs  from 
coma,  or  heart  failure,  or  from  shock.  Previous  to  this  there  is 
successively  to  be  noted,  first,  a  lividity,  and  then  a  palloj  and 
wrinkling  of  the  skin,  with  a  feehng  of  cold  and  numbness  and 
shivering.  The  muscular  and  mental  powers  gradually  fail,  the 
former  interrupted  by  twitchings  and  even  tetanic  spasms  ;  a  deepen- 
ing feeling  of  languor  and  loss  of  sensibiHty,  as  the  senses  become 
dull  and  the  mind  cloudy,  with  a  desire  for  sleep  or,  as  is  sometimes 
the  case,  a  painful  wakefulness.  As  consciousness  is  lost  the 
sufferer  may  roar  and  shout  in  his  delirium,  finally,  with  a  failing 
heart  and  slowed  breathing,  to  subside  into  a  state  of  coma  which 
passes  into  death.  An  overpowering  desire  to  relieve  an  intense 
thirst  by  eating  snow  is  often  a  marked  and  grave  symptom  of  the 
earlier  stages. 

Frostbite  is  a  form  of  gangrene  affecting  the  extremities,  chiefly 
the  fingers,  toes,  ears,  and  nose,  following  on  exposure  to  severe  cold, 
and  characterised  by  a  progressive  redness  of  the  part  with  increased 
sensibiHty  and  tingling,  followed  by  a  change  to  a  bluish  or  purple 
colour,  and  anaesthesia,  which  becomes  more  and  more  intense  as  the 
colour  is  lost ;  the  tissues  later  becoming  white,  hard  and  blood- 
less, and,  finally,  black  and  shrunken,  presenting  all  the  appearances 
of  dry  gangrene.  According  to  the  degree  and  duration  of  the  cold, 
so  may  any  of  these  stages  be  reached,  and  recovery  take  place  with 
more  or  less  loss  of  structure  and  impaired  function. 

The  local  treatment  of  such  a  condition  consists  in  endeavour- 
ing to  restore  the  circulation  by  the  very  gradual  application  of 
warmth  and  by  friction  of  the  affected  part,  which,  if  it  have  become 
gangrenous,  should  be  allowed  to  separate  spontaneously.  The 
general  condition  of  the  patient  may  require  attention. 

2.   Atmospheric   Pressure 

Owing  to  the  practical  impossibility  of  isolating  the  effects  of 
atmospheric  pressure,  within  such  ranges  of  variations  as  are  met  with 
at  the  sea-level  or  usually  inhabited  regions,  from  the  other 
atmospheric  and  climatic  factors,  its  causal  influence  on  diseases 
cannot  be  affirmed.  Nor  can  it  be  solely  held  responsible  with 
certainty  for  the  development  of  symptoms,  such  as  pain,  occurring 
in  the   course  of  already   existing   disease ;    corresponding  in  this 


1 6  MANUAL   OF   MEDICINE 

respect  to  the  influence  of  cold,  damp,  etc.  Its  importance  as  a 
determinant  of  haemorrhage  has  been  much  overstated  ;  carefully 
conducted  observations  going  far  to  prove  the  contrary.  With 
extremes  of  pressure,  however,  such  as  man  is  not  ordinarily  exposed 
to,  there  are  associated  very  constant  symptoms  sufficient  to  constitute 
distinct  diseases,  for  which  the  pressure  itself  may  be  properly 
regarded  as  the  exciting  cause,  just  as  definite  morbid  states  are 
connected  with  extremes  of  heat  or  cold. 

The  fluctuations  of  barometric  pressure  to  which  human  beings 
are  commonly  subjected  range  between  28  and  31  inches;  this,  in 
round  numbers,  would  give  a  pressure  of  about  15  lbs.  in  the  square 
inch,  or,  on  the  whole  surface  of  the  body  of  an  adult  man,  upwards 
of  1 1  tons,  of  which  the  individual  is  ordinarily  insensible  owing  to 
the  pressure  being  equally  exerted  in  all  directions. 

The  effects  that  result  from  raising  or  lowering  the  atmospheric 
pressure  are  of  chemical,  not  mechanical,  origin,  and  the  individual 
succumbs  to  a  species  of  intoxication.  The  partial  pressure  of  the 
oxygen  is  the  one  factor  of  supreme  importance,  and,  in  this  condition, 
whether  it  be  excessive  or  deficient,  the  processes  of  combustion  in 
the  tissues  are  no  longer  carried  to  their  final  end. 

(a)  Increased  atmospheric  pressure  —  caisson  disease.  — 
Exposure  to  much  increased  atmospheric  pressure  occurs  in  mines, 
sinking  wells,  in  diving  bells,  and  more  particularly  in  caissons  which 
are  employed  for  subaqueous  tunnelling  where  the  inrushing 
water  is  kept  back  by  compressed  air.  In  the  latter  situation  work 
is  sometimes  carried  on  in  a  pressure  of  50  to  60  inches,  i.e.  three 
to  four  atmospheres.  A  pressure  above  five  atmospheres  cannot 
be  tolerated  with  safety.  According  to  Paul  Bert  all  life  is  destroyed 
by  an  air-pressure  of  twenty  atmospheres.  Exposed  to  this 
vertebrates  die  in  convulsions  ;  insects  become  paralysed  ;  vegetables 
shrink  up  ;  grains  stop  germinating ;  bacteria  cease  to  ferment.  An 
atmosphere  containing  either  an  oxygen  tension  of  400  mm.  of 
mercury  or  a  carbon  dioxide  tension  of  30  mm.  is  absolutely 
irrespirable.  The  physiological  effects,  or  those  which  can  scarcely 
be  termed  disease  symptoms,  are  briefly  a  general  sense  of  comfort 
with  distinct  increase  of  muscular  power,  which  is  exerted  with  less 
fatigue ;  the  compression  of  the  gases  in  the  stomach  and  intestines 
permits  a  greater  descent  of  the  diaphragm,  whereby  the  respirations 
become  fuller  and  slower  ;  the  pulse  is  less  frequent  and  of  increased 
volume  and  higher  tension ;  the  blood  is  less  venous  and  contains  a 
greater  percentage  of  oxygen  and  nitrogen  than  normal ;  and  the 
secretions  from  the  skin  and  kidneys  are  increased.     Opinions  differ 


DISEASES  EXCITED  BY  ATMOSPHERIC  INFLUENCES  1 7 

as  to  whether  there  is  an  increase  in  the  tissue  metaboKsm, 
although  the  appetite  is  improved  and  muscular  power  increased ; 
for  though  there  may  be  a  slight  rise  of  temperature,  it  is  not 
constant  nor  is  there  any  appreciable  excess  in  the  carbonic  acid  or 
urinary  solids  excreted.  Since  it  is  the  needs  of  the  tissues  them- 
selves which  determine  their  metabolism,  and  the  amount  of  oxygen 
in  the  blood  at  normal  pressure  exceeds  what  is  required,  it  is 
probable  that  there  is  no  constant  increase  in  the  tissue  change,  and 
consequently  none  in  the  waste  products. 

The  incidence  of  morbid  symptoms  among  w^orkers  in  com- 
pressed air  is  very  variable,  but  appears  to  be  largely  conditioned 
by  the  degree  of  pressure,  the  duration  of  stay  in  the  altered 
atmosphere,  and  the  completeness  of  ventilation,  the  last  named 
being,  according  to  Dr.  Snell  {^Compressed  Air  Illness,  by  E.  H. 
Snell,  M.D.,  1896,  with  complete  bibliography),  of  the  utmost 
importance,  whilst  he  relegates  to  a  position  of  subsidiary  im- 
portance the  rapidity  with  which  the  worker  passes  from  the  one 
atmosphere  to  the  other,  which  has  been  generally  regarded  as  a 
dominant  factor  in  the  causation  of  caisson  illness.  Among  pre- 
disposing causes  are  age,  the  older  men  being  more  prone,  specially 
if  there  be  signs  of  degeneration,  alcoholism,  and  previous  want  of 
food,  whilst  those  taking  exertion  immediately  after  leaving  the 
compressed  air  appear  more  liable  to  become  ill.  The  immunity 
of  certain  divers  and  caisson  workers  to  decompression  is  note- 
worthy. This  may  depend  on  greater  elasticity  and  width  of  the 
capillaries,  but  more  probably  on  differences  in  the  gaseous  absorp- 
tion in  different  individuals.  On  experimental  grounds  there  are 
reasons  to  think  that  this  is  controlled  by  some  compensating 
mechanism. 

Symptoms. — These  occur  almost  entirely  after  the  individual 
has  left  the  compressed  air,  coming  on  in  from  a  few  minutes  to  an 
hour  or  more,  seldom  beyond  twelve.  The  most  frequent  are  pains 
in  the  limbs  or  back,  especially  about  the  knees,  of  all  degrees  of 
severity,  even  to  being  excruciating,  sharp,  dull,  or  aching  in  character, 
often  paroxysmal,  and  sometimes  accompanied  by  tenderness  and 
swelling.  They  may  be  the  only  symptoms,  and  usually  subside  in 
a  few  hours,  or  may  be  days,  seldom  lasting  longer.  In  a  variable 
proportion  of  cases  epigastric  pain,  either  alone  or  with  the  fore- 
going, is  met  with,  occasionally  accompanied  with  nausea  or  vomit- 
ing. A  remarkable  and  sudden  form  of  paralysis  with  anaesthesia  some- 
times occurs,  generally  taking  the  form  of  paraplegia,  more  rarely  a 
monoplegia.  This  may  or  may  not  co-exist  with  the  pains  described ; 
VOL.  I  c 


1 8  MANUAL   OF   MEDICINE 

sometimes  it  is  spastic  in  character,  sometimes  tabetic,  with  per- 
manent exaggeration  of  the  reflexes ;  the  bladder  and  rectum  are 
frequently  involved,  and  cystitis  has  been  known  to  supervene. 
Auditory  vertigo,  sometimes  with  deafness  of  one  or  both  ears,  or 
tinnitus,  and  in  severe  cases  with  a  tendency  to  fall  towards  the 
deaf  side,  has  been  noticed.  Among  other  symptoms  of  variable 
frequency  are  a  marked  pallor  of  the  skin,  sometimes  with 
mottling  or  even  ecchymoses,  cold  sweats,  formication,  deafness, 
headache,  diplopia,  epistaxis,  haemoptysis,  and  a  peculiar  dysphagia 
and  feeling  of  obstruction  in  the  gullet.  If  the  entrance  to  the 
compressed  air  chamber  be  sudden,  and  especially  if  there  be  any 
catarrhal  or  other  blocking  of  the  Eustachian  canal  and  passages 
leading  from  the  frontal,  nasal,  and  other  sinlises,  then  severe  pain 
in  the  ear  or  across  the  forehead  may  be  experienced  until  an 
equilibrium  of  pressure  is  established  ;  occasionally  even  the  mem- 
brana  tympani  is  ruptured.  As  a  rule,  complete  recovery  takes 
place  from  all  of  these  symptoms  in  the  course  of  a  few  hours  or  days  ; 
sometimes,  however,  it  may  be  weeks  before  the  patient  is  quite 
well,  and  neuralgic  pains  have  been  k;nown  to  persist  for  longer. 
Now  and  then,  in  a  very  variable  proportion,  death  occurs  very 
shortly  after  passing  into  the  normal  atmosphere ;  unconsciousness 
deepening  into  fatal  coma  is  the  usual  course.  Death  may  be 
postponed  for  many  days  or  weeks,  and  in  such  cases  the  patient 
exhibits  the  symptoms  of  acute  myelitis. 

Post-mortem,  appearances. — Extreme  congestion  of  the  brain, 
cord,  and  meninges,  as  well  as  other  viscera  is  the  most  constant ; 
occasionally  haemorrhages  in  the  arachnoid  space  have  been  met 
with,  and  sometimes  the  appearances  of  myelitis,  with  small  rents  in 
the  substance  of  the  cord  suggestive  of  tearing,  as  by  escaping  gas. 

Pathology. — This  is  undoubtedly  obscure,  the  theories  that 
the  condition  is  due  to  congestion  of  the  brain  and  spinal  cord  from 
pressure  on  the  surface,  or  to  carbonic-acid  poisoning,  are  inade- 
quate, if  not  absolutely  incorrect.  The  most  reasonable  hypothesis 
is  that  in  the  escape  of  bubbles  of  gas  from  the  blood  on  the 
removal  of  the  pressure,  temporary  emboli  of  the  smaller  vessels  are 
found,  causing  transient  or  more  permanent  damage  of  the  nervous 
tissues,  the  latter  probably  due  to  lacerations  caused  by  the  forcible 
escape  of  the  gas.  In  some  measure  the  ill  effects  are  due,  certainly 
in  animals  submitted  to  pressures  exceeding  five  atmospheres,  to 
intoxication  from  the  results  of  perverted  tissue  metabolism. 

Treatment. — Since  most  cases  quickly  recover,  active  treat- 
ment is  seldom  called  for.      Recompression  by  placing  the  patient 


DISEASES  EXCITED  BY  ATMOSPHERIC  INFLUENCES  19 

in  a  suitable  chamber  where  the  atmospheric  pressure  may  be 
increased,  and  sloivly  reducing  the  pressure  to  normal,  is  most 
effective.  Morphia  may  be  required  for  the  pains,  or  anodyne 
applications  to  the  affected  parts.  Some  success  has  been  said  to 
follow  the  administration  of  ergot,  given  to  cause  contraction  of  the 
arterioles  and  so  relieve  the  congestion.  For  the  paralytic  symptoms 
counter-irritation  along  the  dorso-lumbar  region  of  the  spine,  with 
strychnine  internally,  should  be  employed.  It  is  to  prevention,  by 
observance  of  the  precautions  indicated,  that  attention  should  be 
specially  directed. 

ip)  Diminished  atmospheric  pressure — mountain  sickness. 
— An  extreiTiely  rarified  atmosphere,  such  as  is  met  with  on  the 
highest  mountains,  or  in  balloon  ascents,  causes  well-marked  symp- 
toms of  a  serious  character.  Differences  exist — determined  in  great 
measure  by  the  "  condition  "  and  fitness  of  the  individual,  and  the 
degree  of  his  "  vital  capacity  " — as  to  the  power  of  resisting  a  much 
diminished  pressure;  but  at  a  height  of  16,000  feet  and  upwards, 
i.e.  at  about  half  the  normal  pressure,  certain  symptoms  are  mani- 
fested by  all.  The  greatest  heights  attained  have  been  23,000  feet 
in  the  Himalayas,  and  10,000  feet  beyond  that,  or  upwards  of  6 
miles,  in  a  balloon.  At  such  altitudes  as  these  the  coincident  effect 
of  the  great  cold  has  to  be  considered,  and  it  is  impossible  to  separate 
the  influence  of  this  factor  from  that  of  the  low  barometer.  Life  is 
absolutely  impossible  when  the  partial  pressure  of  oxygen  falls  from 
the  normal  (160  mm.  Hg.)  to  40-50  mm.  Hg.  ;  but  the  individual  is 
incapable  of  muscular  activity  at  an  oxygen  pressure  considerably 
higher  than  this.  The  greater  the  rate  of  tissue  metabolism  the  less 
will  be  the  power  of  resistance  to  diminution  of  pressure ;  hence  the 
higher  the  body  temperature,  or  the  lower  the  surrounding  tempera- 
ture, or  the  more  the  amount  of  associated  muscular  effort,  the  greater 
will  be  the  metabolism,  and  the  sooner  will  the  individual  experience 
symptoms  of  distress.  Thus  it  is  that  mountain  climbers  as  a  rule 
commence  to  suffer  at  lower  levels  than  do  aeronauts.  The  greater 
cold,  however,  to  which  the  latter  are  exposed  at  extreme  heights, 
as  well  as  the  greater  rapidity  with  which  those  altitudes  are  reached, 
contribute  in  an  important  degree  to  the  severity  of  the  symptoms 
experienced. 

The  principal  symptoms  are  connected  with  the  cardio-respira- 
tory  functions,  accompanied  by  extreme  lassitude  and  fatigue,  both 
muscular  and  mental.  The  exhaustion  is  remarkable  ;  it  often  super- 
venes suddenly — as,  indeed,  do  most  of  the  symptoms — and  increases 
as  the  person  ascends,  until  there  is  absolute  inability  to  move,  or 


20  MANUAL  OF  MEDICINE 

make  the  slightest  effort.  After  a  brief  rest  progress  may  be  resumed, 
soon  again  to  come  to  a  standstill ;  and  this  may  be  repeated  until 
further  advance  becomes  impossible.  There  may  be  pains  in  the 
muscles  of  the  limbs,  and  the  looseness  of  the  hip-joint  from  lessened 
atmospheric  pressure  has  been  partly  credited  with  the  weakness  of 
the  legs.  The  essential  fact,  however,  is  the  diminished  oxygen 
tension  in  the  blood,  the  imperfect  removal  of  the  carbonic  acid 
therefrom,  and  the  coincident  impaired  metabolism,  upon  which, 
probably,  all  the  symptoms  manifested  more  or  less  directly  depend. 
This  is  especially  so  in  respect  to  the  quickened,  shallow  breathing, 
which  becomes  gasping  and  difficult,  and  finally  the  mouth  is  kept 
widely  open  to  facilitate  inspiration.  The  desire  for  air  is  insatiable. 
Sometimes,  during  the  rapid  sequence  of  the  respirations,  an  oppressive 
pause  occurs,  and  then  there  arises  a  terrible  feeling  of  suffocation. 
The  pulse  is  accelerated  and  soft ;  there  is  palpitation  and  liability  to 
syncope,  and  the  individual  experiences  a  throbbing  of  the  vessels, 
particularly  in  the  head.  This  condition  of  the  circulation  leads  to 
vertigo,  headache,  and,  in  extreme  cases,  to  unconsciousness.  The 
skin  generally  is  pale  and  rugose,  whilst  the  face  is  cyanotic ;  the  per- 
spiration is  suppressed,  and  secretion  of  urine  diminished ;  the  body 
temperature  falls,  and  there  may  be  bleeding  from  the  gums  and 
nose.  These  haemorrhages  are  due  to  venous  congestion,  which 
results  from  vaso-motor  paralysis  and  cardiac  debility,  and  these  in 
their  turn  are  primarily  due  to  want  of  oxygen.  The  appetite  is  lost ; 
but  an  intense  thirst  is  complained  of,  apparently  connected  with  the 
parched  state  of  the  throat.  Nausea  and  vomiting  are  by  no  means 
constant  in  occurrence,  as  the  name  of  the  malady  might  imply.  A 
feeling  of  constriction  at  the  epigastrium  has  been  noticed,  and  also 
deafness  and  earache  from  outward  bulging  of  the  tympanic  mem- 
brane. Except  at  extreme  heights,  individuals  become  acclimatised 
in  time  to  the  atmospheric  conditions,  and  experience  little  or  no 
discomfort.  The  natives  of  Thibet  maintain  an  active  and  vigorous 
existence  at  an  altitude  of  16,000  feet.  The  co-efficient  of  absorp- 
tion of  the  blood  gases  is,  no  doubt,  the  factor  of  the  greatest  im- 
portance in  regard  to  this  immunity,  in  connection  with  which  it  may 
be  mentioned  that  the  number  of  red  corpuscles  is  increased  in 
animals  kept  after  long  periods  at  greatly  diminished  atmospheric 
pressure. 

There  are  no  records  of  diminished  atmospheric  pressure  causing 
the  death  of  human  beings ;  but  experimentally  it  is  found  that  the 
paralysis  deepens,  and  fatal  coma  ensues,  thus  differing  considerably 
from  death  by  asphyxia,  which  occurs  in  convulsions.      Cadaveric 


DISEASES  EXCITED  BY  ATMOSPHERIC  INFLUENCES  21 

rigidity  is  said  to  supervene  at  once,  and  to  be  extreme,  which  also 
does  not  correspond  to  asphyxial  death. 

Those  exposed  to  these  conditions  should  dress  warmly  and 
lightly,  spare  themselves  as  much  muscular  effort  as  possible,  and, 
when  practicable,  take  with  them  a  vessel  of  oxygen  gas,  by  the  in- 
halation of  which  the  symptoms  are  immediately,  though  temporarily, 
relieved. 

3.   Electricity. 

Lightning  stroke. — Nothing  is  known  of  the  influence  on 
health,  whether  favourable  or  the  reverse,  of  the  ordinary  states  of 
atmospheric  electricity.  The  passage  of  a  powerful  current  through 
the  body  is  commonly  fatal  either  at  once  or  after  an  interval  of  a 
few  hours  or  even  days  ;  or  it  may  determine  symptoms  of  a  transient 
or  of  a  permanent  character. 

The  symptoms  exhibited  by  those  who  do  not  succumb  at  once 
are  those  of  more  or  less  severe  shock,  or  of  cerebral  concussion. 
There  is  insensibility,  with  a  small,  scarcely  perceptible  pulse,  and 
slowed,  deep  respiration,  not  always  regular ;  the  skin  is  cool,  and 
the  body  temperature  depressed,  and  the  pupils  are  dilated.  A 
peculiar  expiratory  cry  has  been  sometimes  remarked,  not  apparently 
of  pain  or  consciously  uttered,  but  connected  with  the  disturbance  of 
respiration,  caused  by  the  electric  shock.  The  patient  may  slowly 
recover  in  a  few  hours,  or  it  may  be  a  longer  time,  though  death  has 
been  known  to  follow  several  days  later,  even  after  considerable  im- 
provement. When  consciousness  returns,  attacks  of  intense  pain  are 
sometimes  complained  of,  not  so  much  in  the  neighbourhood  of  any 
wound,  but  in  the  wrists,  or  more  often  in  the  abdomen  and  loins. 
Twitchings  of  the  facial  muscles,  with  extreme  loss  of  power  and 
anaesthesia  in  the  limbs,  impaired  articulation,  deafness  or  noises  in 
the  ears,  defects  of  vision,  and  haemorrhages  from  nose,  ears,  and 
mouth,  and  suppression  of  urine,  are  symptoms  which  occur  in  varying 
frequency  and  degree,  and  may  all  be  quickly  recovered  from.  Some- 
times, however,  more  lasting  effects  result,  continuing  from  the  onset 
or  arising  much  later ;  among  these  are  paralysis,  hemiplegia  and 
paraplegia,  neuralgia,  blindness  or  other  defects  of  sight,  loss  of  taste 
and  smell,  or  of  hearing,  impaired  memory  and  mental  power,  and 
even  insanity. 

Various  theories  have  been  put  forward  as  the  cause  of  death. 
Some  have  considered  that  the  resistance  of  the  tissues  to  the 
current  has  determined  a  rise  of  temperature  which  is  fatal,  and 
though  anything  like  a  general  charring  of  the  body  is  unknown. 


22  MANUAL  OF  MEDICINE 

there  is  usually  some  local  evidence  of  burning  or  scorching,  and  a 
sufficient  rise  of  body  heat  might  be  induced  to  cause  death ;  others 
have  attributed  the  result  to  a  sudden  expansion  of  the  gases  of  the 
blood  and  liberation  of  free  gases  from  decomposition  of  the  tissues ; 
others  again  to  failure  of  the  respiratory  centre ;  but  careful  experi- 
ments strongly  suggest  that  the  main  cause  is  arrest  of  the  heart's 
action,  and  that  in  these  cases,  when  recovery  has  followed  exposure 
to  a  discharge  sufficient  to  kill,  the  current  has  probably  been  con- 
ducted solely  by  the  external  surface  of  the  body  rather  than  by  the 
blood  and  fluids  which  it  usually  traverses,  owing  to  their  lower 
degree  of  resistance.  Recorded  cases  usually,  but  not  always,  show 
that  a  few  respiratory  efforts  are  made  after  the  heart-beat  has 
ceased,  and  the  same  has  been  observed  in  experiments  on  animals 
with  currents  of  high  potential,  when  sometimes  simultaneous 
cessation  of  heart's  action  and  respiration  have  been  noted,  but 
arrest  of  breathing  was  never  found  to  precede  stoppage  of  the 
heart.  The  influence  of  the  current  in  inhibiting  the  heart's  action 
is  considered  by  Drs.  Oliver  and  Bolam  {Brit.  Med.  Journ.  1898, 
Jan.  15)  to  be  directly  exerted  on  the  organ,  and  not  via  the  vagus 
nerve. 

Post-mortem  appearances. — These  may  be  exceedingly 
slight,  but  generally  there  are  some  marks  of  injury  at  the  point 
where  the  current  enters  the  body,  and  frequently  also  at  the  place 
of  exit.  These  appear  as  incised  or  lacerated  wounds  of  the  integu- 
ments and  subjacent  tissues  reaching  even  to  the  underlying  bones, 
which  are  sometimes  fractured  ;  there  is  frequently  a  good  deal  of 
effused  blood,  which  tends  to  exhibit  undue  fluidity  ;  or  there  may 
be  only  an  appearance  of  bruising  and  no  actual  wound.  The 
adjacent  hairs  may  be  singed,  and  some  burning  and  slight  charring 
of  the  integuments,  or  sometimes  a  widespread  appearance  of 
scorching  with  streaks  and  patches  of  variable  size  of  intense  red- 
ness, perhaps  with  blisters.  It  is  seldom  that  there  is  any  burning 
of  the  clothes,  which  are  frequently  torn  to  shreds  and  stript  in  part 
from  the  body,  but  it  is  noteworthy  that  damage  to  the  garments 
by  no  means  necessarily  corresponds  to  the  situation  of  the  surface 
lesions.  Sometimes  remarkable  and  extensive  red  or  purple  dendritic 
markings  are  to  be  seen,  and  it  is  probable  that  the  unequal  contact 
and  pressure  of  the  clothes  has  some  share  in  their  production. 
Internally  no  very  constant  appearances  are  recorded  ;  subserous 
effusions  of  blood  have  been  described  on  the  viscera,  which  are 
sometimes  ruptured,  especially  the  liver  and  brain,  and  a  similar 
accident  has  occurred  to  the  tympanum,       I'he  lungs  are  commonly 


DISEASES  EXCITED  BY  ATMOSPHERIC  INFLUENCES  23 

much  congested.      Rigor  mortis  supervenes  rapidly,  is  of  very  short 
duration,  and  is  quickly  followed  by  decomposition. 

Treatment. — If  the  slightest  evidence  of  life  be  apparent 
artificial  respiration  should  be  at  once  resorted  to  and  continued  for 
at  least  twenty  minutes ;  life  has  undoubtedly  been  thus  saved. 
Stimulants,  such  as  ether  or  brandy,  must  be  administered  hypo- 
dermically  or  by  rectal  injection.  Morphia  may  be  required  for  the 
relief  of  the  excruciating  pains  above  described. 

W.  H.  Allchin. 


24  MANUAL  OF  MEDICINE 


THE  INFECTIONS 

The  infections  or  specific  infective  fevers  form  a  group  of  maladies 
which  result  from  the  introduction  into  the  body  by  wounds,  by  the  air 
passages,  or  by  the  alimentary  tract,  of  specific  bacteria,  each  specific 
infection  being  the  result  of  the  action  of  a  special  microbe,  or  its 
poisons,  on  certain  tissues,  or  groups  of  tissues.  In  many  instances, 
e.g.  tetanus,  typhoid  fever,  tuberculosis,  and  diphtheria,  the  association 
of  cause  (the  microbe)  and  effect  (the  special  form  of  infection)  has  been 
so  fully  and  so  carefully  traced  that  doubt  can  no  longer  exist  in  the 
minds  of  competent  observers  as  to  the  real  cause  of  each  of  these 
diseases. 

In  recent  years  our  knowledge  of  the  spread  of  diseases  produced  by 
bacteria  has  been  so  far  modified  that  some  little  confusion  has  arisen  in 
the  minds  of  various  writers  as  to  the  meaning  of  the  terms  "  infectious  " 
and  "  contagious,"  and  now  many  avoid  the  use  of  either  of  these  words, 
replacing  them  by  the  term  "  infective."  Certain  of  the  diseases  pro- 
duced by  micro-organisms  which  are  of  course  infective  can  scarcely  be 
looked  upon  as  capable  of  being  conveyed  from  one  patient  to  another 
except  in  a  very  roundabout  fashion  ;  it  has  therefore  been  suggested 
that  these  diseases  should  be  spoken  of  as  "non-transmissible,"  whilst 
those  which  pass  readily  from  patient  to  patient  are  "  transmissible." 
Most  if  not  all  epidemic  diseases  are  transmissible  ;  so  also  are  some  of 
the  endemic  diseases,  and  a  few  of  them,  e.g.  paludism  (malaria)  may  be 
said  to  be  transmissible  not  from  patient  to  patient  but  through  an 
intermediate  host.  The  distinctions  that  exist  in  the  mode  of  trans- 
mission from  patient  to  patient  either  directly  or  indirectly  are  of  great 
importance,  and  it  is  only  by  a  careful  study  of  them  that  those  en- 
gaged in  the  prevention  and  cure  of  disease  can  come  to  understand 
them. 

In  a  number  of  diseases — scarlet  fever,  measles,  smallpox,  and  others 
of  a  similar  character — there  \s  prima  facie  evidence  that  similar  causal 
factors  are  at  work  in  their  production,  and  on  the  ground  of  analogy  a 
very  strong  case  for  their  microbic  nature  may  be  made  out,  but  up  to 
the  present  no  conclusive  or  experimental  evidence  in  support  of  this 
has  been  obtained,  and  although  these  and  similar  conditions  are  classed 
with  the  infections,  it  is  because  of  the  clinical  symptoms  and  of  the 
special  transmissibility  of  these  diseases,  and  not  because  of  any  experi- 
mental bacteriological  proof 

In  connection  with  this,  Koch,  for  his  own  guidance  and  that  of 
others  investigating  the  specific  infections,  laid  down  the  following 
postulates,  all   of  which  it  is  necessary  shall  be  fulfilled  before  it  can 


THE  INFECTIONS  25 

be  said  to  be  proved  that  a  micro-organism  is  the  primary  etiological 
factor  in  the  production  of  a  disease. 

I.  The  disease  must  be  of  well-defined  type  and  invariably  accom- 
panied by  {a)  symptoms  so  characteristic  as  to  constitute  a  specific 
malady,  {d)  a  micro-organism  of  constant  form  and  disposed  in  a  con- 
stant relation  to  the  fluids  or  solid  tissues  of  the  host.  2.  Further,  this 
organism  must  be  present  in  the  special  disease  and  in  no  other.  3.  It 
must  be  possible  to  isolate  and  cultivate  this  organism  outside  the 
animal  body,  to  obtain  pure  cultivations  of  such  organism,  and  4,  by 
means  of  inoculation  thereof  to  reproduce  the  disease  with  all  the 
symptoms  of  the  original  complaint,  or  at  least  a  sufficient  number  of 
them  to  give  it  the  specific  character.  5.  In  the  animal  so  affected, 
the  same  organisms  must  be  demonstrable  in  the  same  relation  to  the 
tissues  as  was  obser^-ed  in  the  original  host.  In  such  cases  the  ex- 
perimental proof  is  conclusive. 

Characters  of  the  ^^Iicrobes 

Microbes  or  bacteria  are  low  forms  of  plants  belonging  to  the  group 
of  the  schizomycetes  or  fission  fungi.  These  organisms  consist  of  minute 
specks  from  „  .^^q  in.  (  =  i  jj.)  in  diameter,  or  short  threads  or  rods  from 
I  /i  in  diameter  and  from  1.5  or  2  />i  up  to  6  or  8  /a  or  more  in  length, 
composed  of  vegetable  protoplasm,  each  usually  surrounded  by  a  firmer 
sheath  ;  in  some  instances  this  sheath  is  composed  of  a  substance  re- 
sembling cellulose,  which  in  the  case  of  the  bacillus  tuberculosis  has  on 
its  outer  surface  a  coating  of  some  fatty  acid. 

Multiplication  and  form. — Bacteria  usually  multiply  by  a  process 
of  fission  or  direct  division  ;  each  organism  increasing  in  size  and  then 
dividing  into  two,  the  process  under  favourable  conditions  being  repeated 
at  short  intervals  of  twenty  minutes  or  half  an  hour.  The  fission  may 
be  complete,  the  mother-organism  simply  dividing  into  two  separate  and 
distinct  daughter-organisms;  or  the  two  newly-formed  organisms  may 
remain  in  contact,  sometimes  with  a  slight  bond  of  union  between  them, 
fonning  a  diplococcus  or  diplobacillus.  When  they  undergo  further 
division  and  the  slight  bonds  still  remain,  the  division  going  on  in  one 
plane  only — transversely  to  the  longitudinal  axis — there  is  formed  a  chain 
or  streptococcus  or  string  of  round  beads  like  a  necklet,  or  a  streptobacillus 
or  streptothrix  like  a  string  of  elongated  beads.  In  some  cases  the  rods 
increase  greatly  in  length  without  undergoing  any  marked  division  into 
short  lengths,  and  a  leptothrix  or  slender  thread  is  formed  ;  or  these 
threads  may  assume  a  spiral  or  screw  form,  a  spirillian^  this  again  often 
subdividing  into  short  cur\"ed  segments  v.hich  are  known  as  "  comma- 
shaped"  organisms  or  vibrios^  e.g.  Koch's  comma  bacillus  of  cholera. 
Micrococci  may  be  divided  into  diplococci  (pairs),  streptococci  (chains), 
tetrads  (the  result  of  division   in   two  planes),  sarcince  (or  packets,  the 


26  MANUAL  OF   MEDICINE 

result  of  division  in  three  planes,  in  which  the  groups  are  composed  of 
at  least  eight  cells),  and  staphylococci  (a  mass  somewhat  like  a  bunch  of 
grapes).  In  appropriately-stained  specimens  there  may  be  seen  running 
out  from  some  of  these  micro-organisms  (B.  typhosus,  B.  tetani, 
B.  choleras  asiaticse,  etc.)  lateral  or  terminal  Jiagella  or  cilia^  long  or 
short  delicate  filaments,  single  or  in  groups  or  bundles,  some  motile  and 
wavy,  others  rigid  and  apparently  non-motile. 

Although  in  connection  with  the  infections,  specific  individual  forms 
of  bacteria  are  described,  the  fact  must  not  be  lost  sight  of  that  any 
form  met  with  in  the  animal  tissues  may  be  merely  one  of  a  series,  a 
phase  in  the  existence  of  one  of  these  vegetative  micro-organisms.  For 
example,  a  coccus  under  certain  altered  conditions  may  become  elongated 
into  short  rods,  and  these  again  may,  under  different  conditions,  extend 
into  long  threads.  In  the  case  of  the  ray  fungus — actinomyces — there 
may  be  such  swelling  of  the  ends  of  these  threads  that  they  form  a  series 
of  very  characteristic  club-shaped  organisms,  often  radially  arranged. 
Similarly  the  diphtheria  bacillus  may  occur  as  an  exceedingly  short 
pointed  rod,  or  it  may  grow  out  into  long  filaments,  or  again  it  may 
develop  into  a  perfect  club-shaped  organism. 

The  structure  of  these  microbes  may  be  no  more  complicated  than 
that  above  described,  but  in  some  cases  the  protoplasm  may  be  granular 
or  it  may  be  divided  into  segments,  as  in  bacillus  diphtherise,  or  there 
may  be  seen  clear  and  refractile  bodies  (spores,  resting  spores,  or  seeds)  in 
the  substance  of  the  bacillus,  as  in  the  B.  anthracis,  or  at  one  end  causing 
expansion  of  the  rod,  as  in  B.  tetani  (drumstick  bacillus).  From  these 
spores,  which  are  more  resistant  to  the  action  of  antiseptics,  heat  and 
the  numerous  other  agencies  which  tend  to  interfere  with  vitahty  than 
are  the  bacteria  themselves,  full-grown  or  vegetative  bacteria  may  be 
developed.  The  question  of  spore-formation  is  one  of  special  import- 
ance, especially  in  relation  to  the  stamping  out  of  epidemics,  as  it  is  by 
spores  that  disease  germs,  such  as  those  of  anthrax,  are  able  to  continue 
their  existence  under  unfavourable  conditions.  For  example,  most  non- 
spore-bearing  micro-organisms  when  dried  rapidly  lose  their  vitality  ;  the 
cholera  bacillus,  the  typhoid  bacillus  and  others  sutcumbing,  sometimes  in 
a  few  hours.  Organisms,  on  the  other  hand,  in  which  spores  are  developed 
may  be  dried,  treated  with  chemical  reagents,  frozen,  heated  almost  up 
to  boiling-point,  and  still  afford  evidence  by  their  germination  that  they 
have  retained  their  vitahty.  The  bacillus  anthracis  offers  an  example 
of  the  importance  of  a  knowledge  of  this  matter.  When  confined  to  the 
blood  and  lymph  spaces  in  the  tissues  of  its  host  it  develops  no  spores, 
and  if  the  animal  be  buried  with  unbroken  skin  and  before  the  discharges 
from  the  body  come  in  contact  with  the  air,  the  bacillus  dies  out,  killed 
by  the  organisms  of  decomposition.  Should  the  bacilli,  however,  gain 
access  to  the  air,  spores  which  resist  the  action  of  putrefactive  organisms, 
and  which  may  remain   a  source  of  infection  for  some  time  3,fter  the 


THE   INFECTIONS  27 

diseased  carcase  has  been  buried,  are  very  rapidly  formed.  Splashes  of 
blood  or  of  discharges  containing  spores  represent  foci  from  which  the 
disease  may  spread,  especially  in  farm-yards,  where  there  is  plenty  of 
organic  material  on  which  the  anthrax  bacilli  can  flourish  ;  manure- 
heaps  and  margins  of  ponds  under  these  conditions  offering  specially 
dangerous  centres  of  infection.  For  similar  reasons  the  spores  of  the 
tetanus  bacillus  and  the  bacillus  of  malignant  oedema  are  also  constant 
sources  of  danger  in  any  soil  to  which  they  gain  access. 

Parasitism. — Most  micro-organisms  that  are  capable  of  producing 
an  infective  disease  are  parasitic  ;  they  live,  multiply,  and  carry  on  their 
vital  activities  within  the  body  of  a  living  animal  host  ;  they  are  not 
always  easily  cultivated  outside  the  body,  and  certain  of  them  {e.g.  those 
producing  leprosy  and  relapsing  fever)  have  not  yet  been  so  cultivated. 
These  latter  are  spoken  of  as  '■'•  obligate''''  parasites.  '■'■Facultative'''' 
parasites  are  those  which,  though  usually  found  outside  the  body,  are 
also  capable  of  leading  a  parasitic  existence  in  an  animal  host,  then 
usually  giving  rise  to  definite  pathological  conditions.  A  saprophytic 
micro-organism  is  capable  of  growing  on  dead  organic  matter,  animal 
or  vegetable.  These  saprophytic  organisms  may  become  parasitic,  and 
some  of  them,  such  as  the  anthrax  bacillus,  tetanus  bacillus,  and  bacillus 
of  malignant  oedema,  may  lead  parasitic  and  saprophytic  lives  alternately. 

Although  the  line  of  demarcation  is  never  absolute,  obligate  parasites 
are  usually  confined  to  certain  localities  where  the  conditions  are  such  that 
they  can  be  transmitted  directly  from  individual  to  individual,  whilst  the 
facultative  parasites  which  are  able  to  exist  saprophytically  (as  in  the 
case  of  the  diphtheria  bacillus  or  the  typhoid  bacillus,  which  may  live  in 
milk  and  other  food  substances)  are  exceedingly  dangerous  to  the  health 
of  the  community,  as  are  also  those  which  form  spores,  and  are  thus 
capable  of  continuing  their  species  under  unfavourable  conditions.  It  is 
certainly  far  more  difficult  to  get  rid  of  them  than  of  the  more  easily 
killed  non-spore-bearing  micro-organisms  (such  as  the  cholera  bacilli) 
which  can  live  only  under  very  definite  conditions. 

Pathogenetic  bacteria  exhibit  various  degrees  of  parasitism,  but  it 
may  be  accepted  generally  that  even  the  most  parasitic  have  little 
power  of  remaining  active  in  perfectly  healthy  tissues.  Certain  of  them 
appear  to  alternate  between  a  saprophytic  and  a  parasitic  existence 
(bacillus  cholerse  asiaticas,  streptococcus  pyogenes,  and  bacillus  coli 
communis),  and  during  these  two  phases  they  exhibit  markedly  different 
characteristics  which  sometimes  render  it  difficult  to  realise  that  the 
differences  are  not  something  more  than  merely  variational.  If  cholera 
bacilli  be  examined  directly  they  come  from  a  patient  who  has  succumbed 
to  cholera,  it  is  found  that  they  have,  in  a  high  degree,  the  power  of 
producing  very  active  toxins  from  albuminous  substances.  If,  now,  the 
conditions  be  even  slightly  altered,  or  comparatively  weak  solutions  of 
antiseptics  be  added,  the  bacilli  lose  their  power  of  resista,nce  and  are 


2  8  MANUAL  OF  MEDICINE 

easily  killed,  although  the  activity  with  which  they  performed  their  work 
under  favourable  conditions  appeared  to  be  ver\-  great.  If  these 
organisms  be  cultivated  outside  the  body  for  a  prolonged  period  they 
soon  lose  some  of  their  characteristic  features.  They  still  grow  rapidly 
but  do  not  liquefy  gelatine  at  the  same  rate  as  they  do  in  their  first  few 
generations  after  being  taken  from  the  patient.  They  appear  to  have 
become  more  distinctly  aerobic  in  character  and  to  have  lost  some  of 
their  power  of  producing  large  quantities  of  active  toxic  substances, 
but  on  the  other  hand  they  have  become  much  more  resistant  to  the 
action  of  antiseptic  substances,  heat,  cold,  malnutrition,  and  the  like. 
They  have  indeed  assumed  saprophytic  characters,  and  in  so  doing 
have  become  more  resistant  to  external  influences.  Although  they  are 
now  less  virulent  they  are  more  dangerous  to  the  community,  from  the 
fact  that  they  are  not  nearly  so  readily  got  rid  of,  and  are  therefore 
enabled  to  lie  fallow  and  to  await  an  opportunity  of  attacking  proteid 
material  in  a  fresh  host,  and,  in  their  new  surroundings,  of  regaining 
their  more  virulent  characters  and  toxin-producing  powers.  Here  then 
is  an  organism  which  in  the  parasitic  stage  is  active  but  is  readily  killed, 
whilst  in  the  saprophytic  stage  it  is  far  more  resistant  but  not  so  active 
as  a  disease -producer.  It  is,  for  this  reason,  necessary  to  deal  with 
such  an  organism  as  soon  as  possible  after  it  comes  from  the  body,  as 
it  is  during  this  very  active  phase  that  it  is  least  able  to  defend  itself. 
What  applies  in  the  case  of  the  cholera  bacillus  applies  directly  to  all 
those  organisms  which  have  the  power  of  setting  up  disease  whether 
they  form  spores  or  not,  and  the  fact  must  never  be  lost  sight  of  that, 
although  pathogenetic  organisms  appear  to  become  less  virulent,  their 
greater  resisting  power  renders  them  far  more  dangerous  in  the  produc- 
tion of  epidemics  than  are  the  more  active  but  less  resistant  forms. 

Cultivation  and  results. — Such  micro-organisms  as  have  been 
studied  at  all  carefully  can  be  cultivated  on  sterile  media  of  appropriate 
nature,  broth,  peptone-gelatine,  agar-agar,  solidified  blood  serum,  milk, 
etc.  ;  it  has  thus  been  determined  that  they  have  certain  definite  require- 
ments in  the  way  of  food,  moisture,  and  temperature,  and  only  when 
these  are  complied  with  can  they  do  their  special  work.  All  require 
oxygen,  hydrogen,  carbon,  nitrogen,  and  inorganic  salts,  especially  those 
of  lime  and  potassium.  Unlike  the  higher  plants  they  are  unable  to 
assimilate  carbon  dioxide,  which,  however,  they  produce  in  considerable 
quantities.  Some  of  them,  the  obligatory  "anaerobes,"  or  those  which 
live  only  in  the  absence  of  air,  have  the  power  of  extracting  their  carbon 
and  oxygen  from  starch,  sugars,  organic  acids,  and  the  glycerines.  In 
rare  instances  they  can  derive  them  only  from  proteid  substances. 
Others,  the  obligatory  "  serobes,"  can  only  obtain  the  bulk  of  their 
oxygen  from  the  atmosphere,  whilst  a  third  class,  the  facultative  anaerobes, 
or  cerobes,  as  the  case  may  be,  may  live  under  either  set  of  conditions. 
The    more    distinctly  parasitic    an    organism   is   the   more   necessan,'   it 


THE   INFECTIONS  29 

appears  to  be  that  It  should  have  proteid  material  from  which  to  derive 
the  elements  of  its  nourishment. 

When  micro  -  organisms  are  cultivated  in  suitable  nutrient  media 
arid  growTi  en  masse  it  is  possible  to  determine  some  of  their  specific 
functions.  Certain  of  them  produce  colouring  matter  through  the 
agency  of  an  oxydase  or  colour-producing  enzyme  or  ferment :  a  blood 
red  as  in  the  case  of  the  bacillus  prodigiosus,  a  magenta  by  the  magenta 
micrococcus,  a  violet  by  the  bacillus  violaceus,  a  smoky  blue  by  the 
bacillus  pyocyaneus,  and  other  pigments  by  other  organisms.  Some  of 
these  chromogeiietic  bacteria  have,  in  common  with  others,  the  power  of 
liquefying  a  gelatine  medium^  and  it  is  supposed  that  they  do  this 
through  the  agency  of  a  peptonising  ferment,  which,  in  the  case  of  the 
pus-producing  organisms,  is  a  most  important  factor  in  the  liquefaction 
of  devitalised  tissues.  The  anthrax  bacillus,  especially  when  highly 
parasitic,  exerts  a  similar  action  on  gelatine.  Acids — lactic  acid,  etc., 
ethers,  alcohols  and  other  volatile  substances,  sulphuretted  hydrogen, 
carbon  dioxide,  ammonia,  may  all  be  produced  by  bacteria,  as  also 
may  small  quantities  of  antiseptic  substances,  methylamines,  and  the 
like.  Beyerinck  describes  organisms  which  have  the  power  of  pro- 
ducing a  phosphorescent  glow — the  energy  that  they  derive  from  their 
food  in  this  instance  assuming  the  form  of  light- 
Bacteria  which  are  the  cause  of  specific  infective  disease  require  for 
their  nutrition  much  the  same  elements  as  do  other  bacteria,  but  it  is 
a  noteworthy  fact  that  most  of  them  require  a  larger  proportion  of 
proteid,  especially  albumoses  or  peptones,  than  do  non-pathogenetic 
forms,  especially  for  the  production  of  toxic  substances,  the  cholera 
bacillus,  again  taking  it  as  an  example,  being  most  active  in  producing 
its  toxic  substances  when  it  is  supplied  with  a  certain  proportion  of 
comparatively  crude  albumen.  It  is  for  this  reason  apparently  that  the 
pathogenetic  organisms  undergo  modifications  as  to  their  toxin-forming 
and  pathogenetic  activity  when  they  are  taken  from  the  body  and  are 
compelled  to  live  a  more  or  less  saprophytic  existence,  these  activities 
in  some  instances,  as  in  the  case  of  streptococci,  being  multiplied  to  an 
enormous  extent,  by  continuous  passage  through  a  series  of  animal  hosts. 
In  this  way  may  be  explained  the  rapidly  increasing  severity  of  cases 
at  certain  stages  of  epidemic  outbreaks  of  such  diseases  as  scarlatina, 
typhoid,  cholera,  and  plague. 

Toxic  products  of  bacteria. — That  exceedingly  active  soluble 
poisons  are  formed  by  micro-organisms  is  now  fully  recognised.  Very 
virulent  poisons  absolutely  separable  from  the  micro-organisms  are 
produced  by  tetanus  and  diphtheria  bacilli,  whilst  less  active  poisons 
have  been  obtained  from  the  mahgnant  osdema  bacillus.  The  first  of 
such  poisons  experimentally  produced  were  those  separated  from  septic 
matter  by  Panum  and  described  by  him  as  sepsins.  At  first  they  were 
supposed   to   be   substances    corresponding  to  the  poisonous  vegetable 


30  MANUAL  OF  MEDICINE 

alkaloids,  but  now  they  are  known  to  be  derived  from  much  more 
energetic  non- crystalline  proteid  poisons,  which  on  oxidation  into 
alkaloids,  lose  much  of  their  virulence.  These  toxins  are  probably 
enzymes  or  ferinents^  separated  from  the  organisms  producing  them, 
which,  combined  with  such  molecules  as  globulins,  nucleo- albumins, 
peptones  and  albumoses,  may  have  very  varied  characters.  The  ultimate 
chemical  constitution  of  these  toxins  is  not  yet  known. 

These  amorphous  toxic  products  or  proteid  poisons  may  be  grouped 
as  follows  —  {a)  Those  substances  which  may  be  looked  upon  as  the 
direct  result  of  the  katabolic  processes  of  the  micro-organisms,  their 
secretions  or  rather  their  excreted  waste-products.  {b)  Those  sub- 
stances, also  secreted  but  still  remaining  enclosed  in  the  protoplasm, 
which  are  built  up  at  the  expense  of  outside  materials,  and  are  set  free 
only  in  very  old  cultures,  or  when  the  bacteria  are  treated  with  a  very 
strong  alkali  or  begin  to  undergo  degenerative  changes.  They  may  be 
formed  from  non-proteid  materials,  but  this  is  not  usually  the  case. 
Unlike  the  enzymes  and  specific  toxins  which  form  the  first  group,  they 
are  extremely  resistant  to  the  action  of  heat,  and  may  even  be  boiled 
without  their  specific  properties  being  altered.  When  dissolved  in 
alkalis  they  still  retain  many  of  their  original  properties.  When  dead 
bacilli,  e.g.  tubercle  bacilli,  are  introduced  into  the  body  the  substance 
locked  up  in  them,  when  set  free,  may  give  rise  to  the  characteristic 
local  degenerative  changes.  They  then  attract  leucocytes  by  their  cheniio- 
iactic  power,  and,  secondly,  through  the  poisons  they  contain,  bring 
about  degenerative  changes  and  death,  not  only  of  the  tissues  in  which 
they  are  deposited,  but  also  of  the  leucocytes  that  are  attracted  towards 
them,  (c)  In  addition  to  these,  however,  certain  substances  are  the  direct 
result  of  the  re-arrangement  of  the  molecules  of  the  nutrient  medium  in 
which  the  organism  is  growing,  this  being  usually  brought  about  by  the 
forcible  abstraction  of  certain  atoms  of  the  molecule  by  the  micro- 
organism, {d)  Moreover,  the  action  of  what  is  known  as  the  saprophytic 
function  of  the  organism  upon  the  medium  itself,  as  originally  con- 
stituted, or  upon  the  medium  as  altered  by  the  micro-organism,  may 
also  give  rise  to  certain  bye-products.  It  is  evident  then  that  the 
substances  resulting  from  the  action  of  micro-organisms  upon  a  nutrient 
medium  are  not  only  complex  in  themselves,  but  are  the  result  of  a 
series  of  complex  processes  which  it  is  often  exceedingly  difficult  to 
analyse. 

Many  of  the  pathogenetic  organisms  act  under  ver}^  special  con- 
ditions and  upon  very  complex  proteid  substances.  The  results  vary 
greatly,  but  disintegration  of  these  proteids  is  never  carried  so  far  as 
in  the  ordinary  processes  of  decomposition  of  dead  organic  matter, 
animal  or  vegetable.  Consequently  substances  are  formed  character- 
istic of  the  earlier  stages  of  breaking  down,  viz.  enzymes  (ferments), 
toxins   and  tox-albumens  (proteid  poisons),  albumoses  (partly  digested 


THE  INFECTIONS  31 

albumen),  -ptofnaines  (alkaloidal  poisons),  and  similar  substances  rather 
than  the  simpler  nitrogenous  or  carbon -holding  substances  of  more 
advanced  disintegration — water,  carbon-dioxide,  ammonia,  nitrates,  and 
nitrites,  etc.  In  disease  processes  we  have  the  results  of  the  action  of 
the  products  of  the  earlier  stages  of  decomposition  of  proteid  matter,  at 
which  exceedingly  complex  substances  are  fomied,  rather  than  of  the 
later  stages,  where  decomposition  is  more  fully  carried  out.  By  a 
process  of  hydrolysis  anthrax  and  diphtheria  bacilli  and  their  pro- 
ducts convert  crude  albuminous  material  into  substances  nearly  allied 
to  albumoses.  Hankin  and  Cartwright  Wood  maintain  that  these 
albumoses,  when  injected  into  an  animal,  exert  a  protective  action  each 
against  the  specific  disease  with  which  it  is  associated.  The  enzymes 
or  ferments  which  appear  to  precede  or  to  be  formed  along  with  the 
albumoses  have  in  most  instances  a  much  greater  lethal  activity,  but 
they  appear  to  exert  a  comparatively  slight  protective  effect,  although 
when  injected  sufficiently  carefully  they  give  rise  to  modifications  in  the 
protoplasm  of  the  cells,  which  are  thus  rendered  more  resistant  to  the 
action  of  toxins.  The  albumoses  appear  to  have  a  similar  power  of 
bringing  about  a  modification  of  the  cell,  which  enables  it  to  resist  the 
attacks  of  the  toxin  without  at  the  same  time  exerting  the  powerful 
toxic  influence  which  the  enzymes  exhibit.  This  production  of  albumoses 
or  some  similar  substance  in  disease  is  therefore  of  vital  importance  in 
the  production  of  immunity.  A  number  of  enzymes  which  in  many 
respects  resemble  the  toxins  formed  by  disease-producing  organisms 
have  been  described — amylase,  invertin  ;  enzymes  which  split  up 
glucosides,  cellulose,  urea,  and  fat ;  enzymes  which  have  the  power  of 
peptonising  albuminous  substances  and  converting  them  into  peptones, 
albumoses,  and  similar  proteid  derivatives  ;  chromogenetic  enzymes 
which  have  the  power  of  producing  colouring  matter,  etc.  These 
enzymes  may  remain  and  do  their  work  in  the  cell,  hydrolising  the  cell 
substance,  or  they  may  become  separable  functions  and  do  their  work 
outside  the  cell.  It  has  been  argued  that  the  so-called  anti-toxin  present 
in  the  blood  serum  of  a  patient  recovering  from  an  attack  of  diphtheria 
or  tetanus  is  simply  the  accumulation  of  such  a  "separated  or  separ- 
able function  "  which  can  act  on  the  toxin  outside  instead  of  within  the 
cell.  Upon  this  the  theory  of  the  anti-toxic  treatment  of  these  diseases, 
e.g.  tetanus  and  diphtheria,  may  be  said  to  depend.  The  toxins  are 
exceedingly  complex  substances,  and  although  they  are  frequently  spoken 
of  as  being  specific  poisons,  it  must  be  remembered  that  they  are  prob- 
ably combinations  of  non-specific  substances  with  perhaps  a  single  specific 
poison  (enzyme  ^/z/'j  globulin,  etc.).  In  diphtheria  and  tetanus  toxins, 
for  example,  there  are  certain  common  substances  by  the  actioB  of  which 
fever,  general  symptoms,  or  local  swelling  may  "be  -set  up,  but  in 
addition  to  these  there  is  in  tetanus  toxin  a  specific  substance  which 
exerts  a  selective  action   on   certain   ner\'e    cells,  inducing    the    specia 


32  MANUAL  OF  MEDICINE 

and  characteristic  symptoms  by  which  tetanus  may  be  distinguished 
from  almost  any  other  disease.  In  diphtheria  toxin  too,  along  with  the 
substances  that  produce  general  effects,  are  those  which  pick  out 
portions  of  the  nervous  system,  and,  combining  with  these,  or  acting  upon 
them,  give  rise  to  the  paralytic  symptoms  so  often  developed  during  or 
after  an  attack  of  diphtheria.  Now  it  is  evident  that  in  the  treatment 
of  disease  by  anti-toxins  it  is  necessary  not  only  to  antagonise  the 
specific  but  also  the  general  actions  of  these  poisons.  It  is  possible  to 
imagine  that  substances  which  only  exert  a  specific  effect  may  be  pro- 
duced along  with  others  which  attack  the  general  poisons.  The  specific 
action  is,  however,  always  the  more  difficult  to  obtain.  It  is  possible 
that  by  the  use  of  a  "  general "  anti-toxic  substance  a  patient  might  be 
helped  to  tide  over  the  effects  of  the  action  of  the  specific  toxic  sub- 
stance ;  and  the  possibility  must  be  recognised  that  an  anti-toxin  for 
diphtheria,  for  example,  might  be  of  such  a  character  that  it  would 
enable  the  patient  to  recover,  still  leaving  unaffected  the  specific  action 
on  the  nervous  system.      This,  however,  is  not  probable. 

It  is  of  course  necessary  to  have  this  specific  "  function  "  as  highly 
developed  as  possible  in  all  anti-toxins.  This  can  best  be  effected 
apparently  by  first  treating  the  anti- toxin -bearing  animal  with  the 
albumoses  and  secondly  with  the  toxins.  In  the  complex  tox-albumoses, 
tox-globulines  and  tox-peptones  it  is  difficult  to  make  out  the  exact 
position  of  the  enzyme-like  toxin  which  has  been  obtained  by  Martin, 
Brieger,  Cohn,  and  others  ;  but  there  is  undoubtedly  a  substance  (not  a 
proteid)  which  has  most  of  the  characteristics  of  an  enzyme  (is  very 
susceptible  to  the  action  of  heat,  etc.),  except  that  it  has  a  much  more 
limited  action  than  has  an  ordinary  enzyme,  not  going  on  working  con- 
tinuously and  hydrolising  almost  indefinitely.  It  is  produced  only  by 
specific  micro-organisms,  and  appears  to  have  the  power  of  acting  upon 
certain  forms  of  albumens  and  of  producing  tox-albumens  or  proteid 
toxins. 

Serum,  diagnosis. — In  addition  to  the  anti-toxic  substances  present 
in  the  blood  of  immune  animals  there  appears  to  be  one  which  exerts  a 
peculiar  action  on  the  specific  microbes  associated  with  the  disease  for 
which  the  immunity  has  been  obtained.  This  has  the  power  of  causing 
some  change  in  the  bacteria,  as  a  result  of  which  they  become  less 
motile,  and  run  together  to  form  little  clumps.  This  has  been  termed 
an  agglo7}i€rati7ig  or  aggliitinatiftg  substance^  and  was  first  pointed  out 
in  1889  by  Charrin  and  Roger  in  connection  with  the  serum  from 
animals  immunised  against  the  bacillus  pyocyaneus.  It  was  again 
observed  by  Metschnikoff  in  1891  in  connection  with  the  vibrio 
Metschnikovii  ;  this  organism  losing  its  motility  and  becoming  agglutin- 
ated into  little  masses  in  the  presence  of  serum  from  animals  made 
immune  to  the  action  of  the  vibrio  Metschnikovii.  Three  years  later 
Pfeiffer  pointed  out  that  bacteria  introduced  into  the  peritoneal  cavity  of 


THE  INFECTIONS  33 

■  immune  animals  became  degenerate  and  less  active,  but  he  insisted  that 
this  took  place  only  in  the  peritoneal  cavity.  In  1895  Bordet  and  Max 
Gruber  demonstrated  that  the  same  change  took  place  outside  the  body, 
and  in  1896  Durham  extended  these  observations  very  considerably. 
Widal  was  the  first  observer  to  publish  records  of  cases  in  which  it  was 
obser>-ed  that  the  agglutinating  substances  are  present  in  the  blood  at 
a  very  early  stage  of  an  attack  of  the  disease.  The  important  point,  as 
first  indicated  by  Gruber,  is  that  as  this  substance  is  produced  at  a  very 
early  stage  of  the  disease,  the  method  might  be  utilised  as  an  early 
diagnostic  method.  In  the  case  of  typhoid  fever,  which  may  be  taken 
as  a  typical  example,  it  is  found  that  in  a  certain  proportion  of  cases  a 
dilution  of  the  patient's  serum  with  nine  parts  of  normal  saline  solution 
invariably  gives  the  typhoid  reaction,  i.e.  actively  growing  typhoid  bacilli 
become  inert,  are  massed  in  clumps,  sometimes  in  as  short  a  period  as 
five  minutes,  though  where  the  amount  of  agglutinating  substance  is 
small  complete  agglutination  may  not  occur  until  the  end  of  the  second 
hour,  though  usually  it  is  seen  within  the  first.  Normal  serum,  i.e. 
serum  from  patients  who  have  never  suffered  from  typhoid,  diluted  to 
this  extent  may  also  give  the  reaction  with  the  typhoid  bacillus.  A  more 
or  less  perfect  reaction  is  obtained  with  this  dilution  (i  :  10)  of  typhoid 
serum  with  the  bacillus  enteriditis.  With  the  bacillus  coli  no  reaction 
is  obtained.  With  more  dilute  solutions  of  the  serum,  i  to  30,  healthy 
blood  gives  no  reaction  ;  the  enteriditis  blood  may  give  some  reaction, 
whilst  the  typhoid  reaction  is  usually  obtainable.  It  is  thus  evident 
that  these  substances  have  a  distinctly  specific  action,  and  if  the  solu- 
tions are  dilute  enough  the  test  is  very  reliable.  This  serum  diagnosis 
may  be  applied  to  other  diseases,  but  it  has  found  its  greatest  practical 
application  in  typhoid  fever. 

Resistance  of  the  Tissues 

In  considering  the  infections  it  is  necessary  to  take  into  considera- 
tion two  distinct  elements  :  (i)  the  attacking  agency,  the  micro-organism 
with  its  poisons  ;  (2)  the  mechanism  of  defence  with  which  every  living 
tissue  is  provided,  by  means  of  which  the  invasion  of  the  attacking 
organisms  may  be  repelled.  When  infection  takes  place  the  attacking 
powers  must  be  strong  or  the  resisting  agencies  weak,  and  as  one  or 
other  of  these  preponderates  so  are  the  organisms  killed  and  infection 
prevented,  or  the  parasitic  organisms  prevail,  and  make  good  their 
position  in  the  body.  Every  surface  and  cavity  of  the  body  is  covered 
with  or  lined  by  well-developed  epithelial  cells,  which  have  the  power 
when  in  health  of  resisting  the  attack  of  most  micro-organisms.  It 
is  only  when  these  epitkelial  surfaces  become  impaired,  and  their 
vitality  lowered  by  the  action  of  irritant  material  or  removed  altogether 
by  abrasion,  that  micro-organisms  have  any  chance  of  getting  beyond  the 
VOL.  I  D 


34  MANUAL  OF   MEDICINE 

surface.  Of  course  in  partially  closed  cavities,  where  enormous  numbers 
of  micro-organisms  can  accumulate  and  give  rise  to  their  specific  pro- 
ducts, the  epithelium  may  in  time  become  so  devitalised  by  the  attacks 
of  the  accumulated  poisonous  products  that  it  can  no  longer  resist  the 
advance  of  the  organisms. 

Within  the  tissues  themselves  it  further  appears  that  there  exists  a 
series  of  natural  protective  agencies  which  play  a  very  important  role  in 
the  prevention  of  infection.  For  example,  the  blood  plasma  (Von  Foder) 
and  the  blood  serum  (Nuttall)  exert  a  distinct  inicrobicidal  or  bactericidal 
action  upon  germs,  this  action  varying  apparently  with  the  state  of 
health  or  special  preparation  of  the  individual. 

Then  again  there  is  the  phagocytic  or  devouring  action  of  cells, 
which,  at  first  supposed  to  be  specific,  is  now  coming  to  be  looked  upon 
as  a  general  destroying  and  scavenging  agency.  Phagocytic  cells  go 
about  the  body  taking  up  dead  or  weakened  cells  and  digesting  them 
after  withdrawing  them  from  the  circulation.  Bacteria,  foreign  particles, 
pigment  and  the  like,  are  also  taken  up  by  them  and  carried  from  point 
to  point  or  deposited  in  places  where  they  can  do  but  little  damage. 
These  cells  are  constantly  traversing  the  blood  vessels  (in  increased 
numbers  in  leucocytosis)  and  lymph  channels  ;  they  constitute  an  im- 
portant protective  agency,  as  it  is  held  that,  in  addition  to  the  phago- 
cytic action,  there  exists  a  distinct  bactericidal  substance  in  the  oxyphile 
granules  so  numerous  in  certain  forms  of  leucocyte  ;  and  certainly  the 
greater  the  need  for  them  the  more  do  they  put  themselves  in  evidence. 
It  is  perhaps  for  this  reason  that  we  associate  them  so  directly  with 
processes  of  disease.  When  pathogenetic  organisms — irritating  foreign 
bodies — have  made  their  way  into  the  tissues,  attracted  there  by  organ- 
isms or  their  products  of  action  and  interaction  upon  the  fluids  and 
tissues  (chemiotaxis),  phagocytes  immediately  engage  the  advancing 
organisms.  At  those  points  where  there  is  a  constant  danger  of  in- 
vasion, as  at  the  top  of  the  throat  (tonsils)  and  in  the  lower  part  of  the 
intestine  (Beyer's  patches  and  solitary  glands),  accumulations  of  these 
cells  are  met  with,  which  may  be  looked  upon  as  normal  phagocytic 
structures.  In  the  lymphatic  glands  in  the  axilla  and  groin  are  similar 
masses  of  active  cells,  which  have  the  power  of  devouring  any  foreign 
particles.  When  these  phagocytic  cells  are  badly  nourished  or  over- 
worked they  are  no  longer  able  to  cope  with  the  invading  disease 
germs  as  they  are  when  active  and  well  nourished  and  with  every 
opportunity  of  getting  rid  of  their  effete  products.  Nourishment,  rest, 
and  the  removal  of  effete  products  have  the  same  influence  upon  the 
condition  of  the  individual  cells  of  the  body  that  they  have  upon  the 
body  as  a  whole  ;  such  cells  require  not  only  exercise,  but  food  and 
rest,  just  as  surely  as  do  our  brains  and  muscles,  and  unless  they  obtain 
them,  and  other  favourable  conditions  are  maintained,  they  cannot 
perform  either  their  scavenging  or  protective  functions   properly,   and 


THE   INFECTIONS  35 

they  and  the  individual  are  laid  open  to  the  attacks  of  pathogenetic 
germs. 

In  recent  years  so  much  attention  has  been  directed  to  the  connec- 
tive tissue  protective  agencies  that  there  may  have  been  some  danger  of 
the  importance  oi  the  part  that  various  functionally  active  organs  play 
ill  the  preventio7t  of  disease  being  overlooked  ;  but  remembering  the 
share  that  the  suprarenal  body  and  the  thyroid  gland,  with  their  secre- 
tions, the  spleen,  the  liver,  the  kidney,  the  intestine,  and  the  bone  marrow, 
take  in  the  formation  of  blood,  in  the  elimination  of  waste  products,  and 
in  similar  operations,  one  cannot  but  be  struck  by  the  fact  that,  should 
any  of  these  have  their  vitality  lowered  or  their  activity  impaired,  they 
must  necessarily  leave  the  body  more  open  to  attack  than  when  they  are 
performing  their  functions  properly.  It  is  therefore  necessary  to  insist 
not  only  upon  the  activity  of  the  disease-producing  germs  as  a  causal 
agent,  but  also  upon  the  weakness  of  the  tissues,  or  the  functional  dis- 
turbances of  the  various  organs  as  powerful  predisposing  causes.  The 
part  that  the  liver  plays  in  protecting  the  body  not  only  against  ingested 
poisonous  substances,  but  also  against  certain  of  the  products  of  diges- 
tion formed  in  the  stomach  and  alimentary  canal  (autogenetic  poisons), 
may  be  instanced  as  an  example.  This  organ  acts  as  a  kind  of  storehouse 
not  only  for  food  materials  but  also  for  toxic  substances,  retaining  them  in 
bulk  as  it  were,  and  allowing  them  to  pass  into  the  general  circulation 
only  in  such  amount  as  may  easily  be  eliminated  without  much  damage 
being  done  to  the  organism  as  a  whole.  Again,  bile  has  a  very  marked 
effect  in  destroying  or  neutralising  the  activity  of  certain  poisons,  e.g. 
snake  venom,  and  the  state  of  the  bile  secretion  probably  has  a  distinct 
influence  on  the  destruction  both  of  poisons  and  micro-organisms  that 
may  be  found  in  the  intestines.  The  secretions  of  the  stomach  and  the 
intestines,  and  even  those  of  the  salivary-  glands  exert  a  germicidal 
effect  on  bacteria,  so  that  any  alteration  brought  about  in  them  may 
readily  be  a  predisposing  factor  in  the  production  of  infective  disease. 
Not  only  the  micro-organisms,  then,  but  also  their  power  of  producing 
poisons,  the  condition,  general  health  of  the  patient  and  his  tissues,  and 
the  character,  normal  or  abnormal,  of  the  secretions  and  their  power  of 
destroying  toxins  or  the  toxin -producing  organisms  themselves,  must 
all  be  considered  as  playing  a  part  in  the  production  of  this  class  of 
disease. 

Immunity. — It  has  been  obsen-ed  in  connection  with  the  incidence 
of  the  infections  that  some  individuals  are  decidedly  less  susceptible  to  the 
attacks  of  certain  of  them  than  are  others.  It  has  also  been  noted  that 
certain  races  resist  the  attacks  of  one  disease,  but  are  more  liable  to  the 
attacks  of  others.  For  example,  it  is  said  that  although  a  negro  of  West 
Africa  is  comparatively  immune  to  the  action  of  the  malaria  materies  inorbi, 
he  may  be  very  susceptible  to  the  action  of  the  tubercle  bacillus  ;  whilst 
the  Indian,  though  somewhat  less  susceptible  to  typhoid  than  the  Anglo- 


36  MANUAL  OF  MEDICINE 

Saxon,  is  much  more  readily  attacked  by  bubonic  plague.  Numerous 
other  examples  of  racial  immunity  and  susceptibility  might  be  given — 
as,  for  instance,  the  extreme  susceptibility  of  the  North  American  Indian 
to  measles  and  smallpox.  As  the  conditions  are  not  absolutely  sharply 
defined,  and  as  other  factors  connected  with  artificial  immunity  here 
come  into  play,  it  is  perhaps  well  not  to  insist  too  strongly  upon  this 
special  form  of  insusceptibility.  A  single  attack  of  certain  diseases 
induces  a  most  marked  protection  against  future  attacks,  and  now  that 
it  is  possible,  by  experiment  on  animals,  to  produce  by  the  injection  of 
micro-organisms  or  their  products  the  important  and  characteristic 
symptoms  of  many  of  these  specific  infective  diseases,  we  can  gatl  er 
and  arrange  numerous  observations  on  this  point,  and  draw  certain 
deductions  from  them. 

It  may  be  well  to  point  out  that  there  is  no  such  thing  as  absolute 
immunity,  and  that  the  term  is  used  entirely  in  a  relative  sense,  as 
indicating  a  greater  or  less  degree  of  insusceptibility  to  the  attacks  of 
certain  diseases.  The  hen,  for  example,  is  naturally  immune  or  in- 
susceptible to  the  attack  of  the  anthrax  bacillus,  though,  when  the 
temperature  of  the  fowl  is  lowered,  it  may  lose  much  of  this  insuscepti- 
bility. An  acquired  immunity  is  really  an  insusceptibility  induced 
through  the  production  of  antitoxin,  through  the  strengthening  of  the 
tissues  and  their  cells,  or  through  a  specific  modification  of  the  cells,  as 
a  result  of  which  they  are  enabled  to  carry  on  their  work  in  the  presence 
of  parasitic  bacteria  and  their  poisons. 

It  will  be  well  to  take  as  an  example  a  specific  disease  for  the  pur- 
pose of  illustrating  the  action  of  micro-organisms  in  the  production  of 
disease,  local  and  general,  and  t-o  show  how,  in  the  course  of  such  a 
disease,  there  is  a  development  of  certain  qualities  and  substances  in  the 
tissues  and  in  the  blood,  by  means  of  which  the  patient  is  protected 
against  future  attacks  for  longer  or  shorter  periods. 

If  small  fragments  of  the  fresh  membrane  removed  from  the  fauces 
of  a  patient  sufifering  from  diphtheria  be  teased  out  on  a  slide,  and  then 
pressed  out  with  a  cover-glass,  and  the  resulting  preparations  stained, 
one  in  methylene  blue  and  another  by  Gram's  method,  there  may  usually 
be  found  in  them,  on  microscopic  examination,  a  number  of  slightly 
curved  or  pointed  rod-shaped  bacilli,  which,  in  the  methylene  blue  pre- 
paration, have  transverse  markings  of  light  and  dark  bands.  Along  with 
these  rods,  diphtheria  bacilli,  which  are  sometimes  clubbed  at  the  ends, 
and  occur  singly  or  in  small  irregular  groups,  and  are  the  active  specific 
agents  in  the  production  of  local  and  constitutional  symptoms  of  diphtheria, 
there  may  also  be  found  a  number  of  rounded  or  ovoid  organisms  arranged 
in  clumps  or  chains,  these  being  seen  in  greater  numbers  in  the  methy- 
lene blue  than  in  the  Gram-stained  specimen.  The  diphtheria  bacillus 
carried,  directly  or  indirectly,  from  some  other  patient  to  the  mucous 
membrane  of  the  uvula  and  tonsils^  especially  when  these  are  ulcerated 


THE   INFECTIONS  37 

or  inflamed,  produces  in  the  albuminous  exudation  in  and  on  which  it 
lives  and  feeds,  a  series  of  substances,  some  of  which  appear  to  exert  a 
distinct  local  necrotic  effect ;  others  again  produce  rise  of  temperature, 
etc.  That  this  is  not  a  fanciful  description  may  be  proved  by  direct 
experiment,  as  pure  cultures  of  the  diphtheria  bacillus,  grown  in  peptone 
broth,  with  or  without  crude  albumen,  are  found  to  contain  all  these 
various  substances,  even  after  the  bacilli  have  been  removed  by  means 
of  careful  filtration.  In  the  majority  of  cases  the  diphtheria  baciUi  are 
confined  strictly  to  the  lesion  in  the  throat,  where,  however,  they  form 
their  toxins  in  such  large  quantities  that,  as  they  are  absorbed,  the 
patient  exhibits  the  constitutional  symptoms  characteristic  of  diphtheria. 

How  far-reaching  and  profound  is  the  action  of  this  toxin  may  be 
gathered  from  the  fact  that  as  it  is  excreted  by  the  kidney  it  gives  rise 
to  cloudy  swelling  of  the  epithelium  lining  the  convoluted  tubules  of  that 
organ.  It  sets  up  similar  changes  in  the  parenchymatous  cells  of  the 
liver.  In  the  wall  of  the  heart,  especially  during  the  later  stages  of  the 
disease,  the  muscle  fibres  are  found  to  be  undergoing  a  fatty  degenerative 
change,  in  form  similar  to  that  following  on  cloudy  swelling,  whilst  some 
of  the  voluntary  nerves  and  muscles,  especially  those  of  delicate  structure 
and  that  are  constantly  in  use,  are  undergoing  similar  changes.  In  the 
local  lesion  it  is  found  that  the  false  membrane  usually  consists  of  the 
epithelial  cells  of  the  part  embedded  in  fibrinous  lymph,  with  diphtheria 
bacilli  on  and  near  the  surface.  The  cells  undergo  a  rapid  degenerative 
change  kno\\"n  as  "  coagulation  necrosis,"  this  often  at  some  little 
distance  from  the  diphtheria  bacilli  on  the  surface  of  the  false  membrane. 

In  very  acute  cases  terminating  fatally,  this  localisation  of  the 
diphtheria  bacillus  may  not  be  maintained  ;  the  toxin  breaks  down 
the  powers  of  resistance  of  the  tissues  by  which  the  bacillus  is  kept 
in  check,  causing  such  degeneration  of  the  comparatively  resistant 
cells  forming  the  wall  of  the  minute  blood  vessels  that  the  blood  is 
allowed  to  escape  from  its  proper  bounds  into  the  surrounding  tissues, 
thus  giving  rise  to  what  is  known  as  "  hsemorrhagic "  diphtheria,  or 
diphtheria  in  which  haemorrhages  into  the  skin  and  mucous  membranes 
constitute  a  characteristic  feature.  If,  however,  recover)^  is  rapid  and 
the  diphtheria  bacilli  disappear  from  the  throat,  the  patient  usually 
possesses  a  certain  degree  of  immunity  against  a  second  attack,  though 
such  immune  condition  is  of  but  short  duration.  During  the  attack  of 
the  disease  certain  changes  have  taken  place  in  the  tissues,  and  substances 
have  been  produced  and  have  accumulated  in  the  fluids  of  the  body  by 
means  of  which  the  action  of  the  toxin  produced  by  the  diphtheria 
bacillus  is  neutralised.  That  this  protection  is  the  result  of  the  action 
of  substances  produced  by  the  diphtheria  bacillus  upon  the  tissues  of  the 
body  we  have  evidence  in  the  fact  that  if  small  quantities  of  a  filtered 
broth  culture  of  the  diphtheria  bacillus,  or,  still  better,  a  culture  growm 
in  serum  peptone  broth,  be  injected  at  first  in  small  quantities  and  then 


38  MANUAL  OF   MEDICINE 

in  gradually  increasing  doses  under  the  skin  of  a  sheep,  rabbit,  or  horse, 
care  being  taken  to  produce  a  local  swelling  and  a  rise  in  temperature 
as  the  result  of  each  injection,  and  to  make  the  next  injection  before  the 
effects  of  the  last  has  passed  off,  two  things  will  occur  :  (i)  the  tissues  of 
the  animal  react  less  and  less  each  time  to  the  same  dose  or  even  to 
increased  doses  of  the  toxin  ;  and  (2)  the  blood  of  the  injected  animal 
or  the  serum  separated  from  it  is  found  to  have  acquired  the  property  of 
neutralising  the  action  of  the  diphtheria  toxin  when  mixed  with  that 
substance  before  it  is  injected  into  the  subcutaneous  tissues  of  an 
experimental  animal.  It  appears  that  this  substance,  so  long  as  it 
remains  in  the  body,  has  the  power  of  protecting  an  animal  against  the 
action  of  the  diphthejia  toxin  ;  it  is  an  anti-toxin.  More  than  this, 
however,  it  has  the  power,  when  mixed  with  the  toxin  in  a  test-tube,  of 
completely  neutralising  the  action  of  this  toxin  and  of  rendering  it  inert 
when  injected  into  the  body — at  any  rate  so  far  as  its  lethal  and  other 
obvious  noxious  properties  are  concerned.  The  substance  contained  in 
the  blood  has  at  present  not  been  obtained  as  a  chemically  pure  sub- 
stance, but  it  is  evidently  a  material  of  very  great  potency.  Its  properties 
have  only  been  studied  by  their  effects  in  neutralising  toxin — hence  the 
name  "  anti-toxin."  The  serum  in  which  it  is  contained  is  known  as 
anti-toxic  serum.  Further,  by  the  introduction  of  small  quantities  of  this 
anti-toxic  serum,  animals  may  be  rendered  temporarily  insusceptible  to 
the  action  of  the  diphtheria  poison.  They  are  in  fact  protected  against 
the  disease,  and  are  said  to  have  acquired  a  degree  of  ^'■passive" 
iin/iiunily.  This  passive  (or  hematogenic)  immunity  is  entirely  the 
result  of  the  presence  of  an  anti-toxic  substance,  which  has  been  pro- 
duced in  another  animal,  circulating  in  the  fluids  of  the  body  of  the 
new  host.  It  at  once  seizes  upon  and  neutrahses  any  toxin  that  may 
be  absorbed  from  without,  which  thus  never  remains  uncombined  or 
free  to  exert  its  specific  action  upon  the  cells  of  the  body,  especially 
those  of  the  nervous  system.  As  soon,  however,  as  the  anti-toxin  has 
been  neutralised  by  a  sufficient  amount  of  toxin  or  has  been  excreted 
from  the  body  by  the  various  emunctory  channels,  the  animal  or  patient 
is  no  longer  protected.  This  "passive"  (Ehrlich)  or  "anti-toxic" 
(Behring)  immunity  may  therefore  be  characterised  as  of  a  purely 
temporary  character,  unless  the  serum  injected  be  derived  from  an 
animal  of  the  same  species  as  that  which  is  being  treated,  when,  accord- 
ing to  Ransom,  the  immunity  is  more  prolonged. 

It  is  possible,  however,  to  produce  in  an  animal  or  in  a  human  being 
an  immunity  of  a  much  higher  order  and  of  a  more  enduring  character. 
It  has  already  been  pointed  out  that  doses  of  toxin  gradually  increasing 
in  quantity  may  be  administered  to  an  animal,  until  enormous  doses  may 
be  given  without  producing  any  very  serious  effect. .  Let  a  standard 
lethal  dose  of  diphtheria  toxin  for  a  horse  be  taken  as  being  represented 
by  I  c.c.  of  toxin.      One  of  these  animals,  by  first  receiving  injections  of 


THE  INFECTIONS  39 

smaller  quantities  than  i  c.c,  and  then  of  increasingly  large  doses, 
may  in  the  course  of  a  comparatively  short  time  be  brought  to  withstand 
the  action  not  only  of  i  c.c.  of  the  toxin  but  of  as  much  as  500  or 
1000  times  that  quantity.  It  is  found,  moreover,  that  this  high  degree 
of  immunity  may  be  maintained  for  a  considerable  period.  Such 
immunity  is  spoken  of  as  being  '■'■active"  (Ehrlich)  or  '■' isopathic" 
(Behring),  and  the  reason  for  this  appears  to  be  that  it  is  due  not 
merely  to  the  presence  of  anti-toxic  substances  already  present  in  the 
body,  but  to  the  fact  that  owing  to  the  continued  action  of  large 
quantities  of  toxin  upon  the  tissue  cells,  these  cells  have,  as  the  result 
of  a  special  stimulation,  acquired  the  power  of  producing,  even  under 
ordinar)'  non-specific  stimulation,  a  considerable  amount  of  anti-toxin, 
so  that  as  that  which  is  in  the  circulation  is  neutralised  or  excreted, 
fresh  supplies  are  constantly  poured  in  from  the  cells  that  have  acquired 
the  habit  of  producing  anti-toxin  (histogenous  immunity).  Let  us  apply 
what  has  been  proved  in  the  case  of  diphtheria  to  the  other  febrile 
diseases,  to  smallpox,  scarlet  fever,  and  similar  conditions  in  which  an 
immunity  is  produced  by  one  attack  of  the  disease,  and  we  have  a  good 
working  theory'  as  to  the  causation  of  disease  or  of  certain  of  the  symp- 
toms and  pathological  conditions  occurring  during  the  course  of  such 
disease,  and  an  explanation,  as  yet  more  or  less  imperfect,  of  the  method 
of  production  of  the  resulting  immunity.  In  vaccination  as  a  protection 
against  smallpox,  "vaccine"  or  the  fluid  from  (n^it'^isa' vesicles  is  used 
as  the  immunising  substance  instead  of  the  more  virulent  smallpox 
virus.  When  the  living  smallpox  virus  or  other  virus  is  introduced  or 
injected  under  the  skin,  the  disease  is  said  to  be  inoculated. 

As  already  pointed  out,  in  some  acute  infections  a  certain  degree  of 
protection  against  any  further  attacks  may  be  conferred  by  the  first. 
In  typhoid  and  scarlet  fevers,  measles  and  smallpox,  the  insuscepti- 
bility may  remain  with  the  patient  for  a  considerable  period.  On  the 
other  hand,  in  such  conditions  as  influenza,  a  first  attack  appears  to 
confer  little  if  any  immunity  ;  indeed  it  appears  to  be  the  general 
experience  that  the  first  attack  predisposes  to  a  subsequent  one,  whilst 
in  the  case  of  a  number  of  other  diseases,  of  which  diphtheria  may  be 
taken  as  an  example,  any  degree  of  protection  that  is  usually  conferred 
is  very  transient. 

Predisposition 

It  may  be  stated  generally  that  the  more  powerfully  parasitic  a 
micro-organism  is,  and  the  more  luxuriantly  it  flourishes  in  the  animal 
body,  the  less  are  any  predisposing  causes  required  to  bring  about 
infection,  but  the  more  rapidly  should  it  be  possible  to  cope  with  an 
outbreak  of  the  disease,  especially  if  the  disease  runs  a  comparativelv 
rapid  course.     When  the  course  of  a  disease  is  more  prolonged,  as,  for 


40  MANUAL  OF  MEDICINE 

example,  in  the  case  of  tuberculosis,  the  infective  material  is  thrown  off 
in  considerable  quantities  over  this  prolonged  period,  and  the  danger  of 
infection  is  of  course  increased.  Where  a  disease-producing  organism 
is  more  saprophytic  in  character  the  danger  of  infection  becomes  much 
greater,  especially  in  those  localities  in  which  the  disease  is  endemic  ;  in 
such  a  case,  however,  it  will  be  found  that  the  importance  of  the  ques- 
tion of  predisposition  becomes  enormously  increased,  and  it  may  fairly 
be  said  that  if  it  were  possible  for  residents  to  maintain  a  condition  of 
perfect  health  apart  from  the  endemic  disease,  that  this  latter  would 
have  very  little  power  of  attacking  them.  It  may  be  said  of  almost 
all  infective  diseases,  however,  that  they  have  little  or  no  chance  of 
gaining  a  foothold  in  the  human  body  unless  there  be  disease  of  some 
kind,  or  weakening  of  the  tissues,  or  a  distinct  lesion,  in  which  the 
organisms  may  find  a  nidus  and  sufficient  and  suitable  nutriment. 

It  is  for  the  physician  to  consider  carefully  what  these  predisposing 
causes  are,  as  during  an  epidemic  he  may  at  any  time  be  called  upon 
to  advise  those  under  his  charge  as  to  the  best  means  of  avoiding  the 
prevailing  disease.  It  has  been  pointed  out  by  Koch,  and  further 
emphasised  by  M'Leod,  that  a  normal  healthy  guinea-pig  is  absolutely 
immune  to  the  attacks  of  the  cholera  bacillus.  When,  however,  the 
acid  secretion  is  neutralised  by  the  introduction  of  an  alkaline  fluid  into 
the  stomach,  and  when  at  the  same  time  the  peristaltic  action  of  the 
intestine  is  interfered  with  by  the  exhibition  of  morphia,  the  cholera 
organism  is  enabled  to  run  the  gauntlet  of  the  stomach,  and  to  multiply 
in  the  intestine  to  such  an  extent  that  it  can  produce  a  sufficient 
amount  of  its  toxins  to  kill  the  guinea-pig  with  the  utmost  certainty. 
Here  there  has  been  produced  by  artificial  means  a  predisposing  con- 
dition, the  series  of  natural  resistances  being  for  the  time  removed. 

Similarly  it  has  been  found  that  animals  kept  at  a  low  temperature 
and  on  starvation  diet  become  extremely  susceptible  to  the  action  of 
certain  disease-producing  germs  ;  whilst  an  atmosphere  containing  sewer 
gas,  or  an  excessive  amount  of  carbonic-acid  gas,  and  exhaled  organic 
matter,  may  also  predispose  to  the  action,  say,  of  the  typhoid  germ. 
Certain  rash  experimenters,  confident  of  the  good  condition  of  their 
digestive  apparatus,  have  from  time  to  time  taken  into  their  stomach 
cholera  and  typhoid  germs  in  the  form  of  pills,  and  the  results  have  been 
negative  ;  but  it  is  well  known  unfortunately  through  a  very  large  number 
of  well-recorded  cases,  that  these  same  germs  when  taken  in  water  have 
produced  very  definite  disease.  During  an  epidemic  produced  by  water- 
borne  cholera  or  typhoid  organisms,  it  has  often  been  noted  that  only  a 
proportion  of  those  who  have  consumed  the  infected  water  are  affected. 
All  must  have  received  a  dose  of  the  bacilli,  but  all  are  not  attacked  by 
the  disease.  This  difference  must  undoubtedly  be  due  in  part  to  a 
difference  in  the  general  resisting  power  of  the  patient,  though  in  some 
cases  it  may  be  that  a  specific  immunity  has  been  conferred,  sometimes 


THE   INFECTIONS  41 

by  an  attack  of  the  disease,  and  sometimes  imperceptibly  through  a 
long-continued  exposure  to  gradually  increasing  doses  of  the  toxin  or 
specific  organic  substances.  I  have  obtained  direct  evidence,  for 
example,  that  the  acid  gastric  juice  exerts  a  most  maiked  effect  in 
diminishing  the  activity  of  the  tubercle  bacillus  and  of  the  cholera 
bacillus.  It  has  been  noted  by  Metschnikoff  that  during  an  epidemic 
of  cholera  large  numbers  of  the  specific  bacilli  have  been  found  in  the 
intestines  of  healthy  individuals,  and  it  may  be  accepted  as  the  outcome 
of  Hueppe  and  Cartwright  Wood's  observations  that  until  there  is  some 
inflammation  of  the  walls  of  the  intestine,  accompanied  by  the  pouring 
out  of  an  albuminous  fluid,  such  as  is  contained  in  serous  exudation,  no 
marked  multiplication  of  the  cholera  organisms  and  no  appreciable 
quantity  of  specific  toxin  is  produced  in  the  intestine. 

All  the  early  experiments  with  the  products  of  micro-organisms  were 
carried  out  for  the  purpose  of  obtaining  substances  which  would  act  as 
prophylactics — which  would  prevent  disease  ;  and  vaccination  and  in- 
oculations for  the  production  of  other  immunities  were  all  directed  to 
such  prevention.  Pasteur's  treatment  for  hydrophobia,  however,  went 
far  beyond  this,  and  his  inoculations  were  distinctly  curative  in  their 
action,  in  so  far  as  the  treatment  was  not  begun  until  the  disease  had 
been  inoculated  by  a  bite.  In  the  case  of  the  antitoxic  sera,  however, 
a  still  further  advance  was  made  ;  the  diphtheria  antitoxic  serum,  for 
example,  being  given  for  the  purpose  of  neutralising  diphtheria  toxin 
and  of  curing  the  disease  in  so  far  that  no  further  damage  is  done  to 
the  tissues.  Such  serum  is  secondarily  a  prophylactic,  but  up  to  the 
present  its  main  use  has  been  the  cutting  short  of  active  disease. 

General  Course  and  Characters  of  the  Infective  Diseases 

Proceeding  to  consider  the  method  of  production  of  the  specific 
infective  fevers,  it  may  be  well  to  note  what  takes  place  when  a  single 
germ  of  yeast,  say,  is  introduced  into  any  fluid  which  contains  the 
materials  necessary  for  its  nutrition.  If  a  suitable  temperature  be 
maintained,  and  no  antiseptics  are  present  along  with  the  necessary 
nutrient  substances  in  the  fluid,  the  germ  begins  to  grow  and  multiply 
with  great  rapidity.  It  uses  up  nitrogenous  and  saccharine  matter,  the 
fluid  becomes  turbid,  and  alcohol,  carbonic-acid  gas,  and  a  number  of 
other  substances  are  produced.  Other  organisms  placed  under  similar 
conditions  produce  colouring"  matter,  others  aromatic  or  exceedingly 
foul-smelling  gases  ;  others  again  give  rise  to  the  production  of  enzymes 
or  ferments  and  peptonising  substances.  A  single  organism  being  in 
most  instances  sufficient  to  start  a  growth  very  soon  makes  itself  mani- 
fest, both  by  its  own  presence  in  large  numbers  and  by  the  character 
of  its  products.  Exactly  the  same  sequence  of  events  takes  place  in 
the  human  body  when  disease  germs  gain  access  to  its  tissues.      Such 


42  MANUAL  OF  MEDICINE 

germs,  to  maintain  their  position,  must  be  endowed  with  a  certain  power 
of  maintaining  a  parasitic  existence.  Unlike  saprophytic  organisms, 
which,  ahhough  they  may  have  the  power  of  producing  active  poisons, 
are  unable  to  exist  in  the  fluids  and  tissues  of  the  body,  they  have  the 
power,  especially  when  the  tissues  are  taken  at  any  disadvantage,  of 
multiplying  and  of  producing  their  products  —  sometimes  in  large 
quantities — and  acute  specific  fevers,  which  run  a  very  definite  course, 
are  the  result.  Each  fever  has  its  course  divided  into  a  series  of  stages, 
each  one  associated  with  some  phase  in  the  action  and  reaction  between 
the  invading  micro-organisms  and  the  tissues  of  the  invaded  organism. 

Between  the  time  at  which  a  patient  is  exposed  to  a  definite  infection 
and  the  period  at  which  the  disease  manifests  itself  {stage  of  invasion) 
there  is  a  period  known  as  the  incubation  period.  Following  this  comes 
Xhe.  period  of  ^'' fever"  then  a  period  of  lysis  in  some  cases,  of  crisis  in 
others — i.e.  gradual  or  rapid  diminution  of  the  fever  {defervescence),  and, 
lastly,  a  period  of  convalescence.  These  periods  may  be  said  to  cor- 
respond generally  to  the  phases  through  which  a  fermenting  or  fermented 
fluid  passes.  When  the  single  grain  of  yeast  is  added,  little  or  no 
change  may  be  observed  for  some  considerable  time,  so  in  the  case  of 
the  specific  infective  fever  there  may  be  no  marked  evidence  of  any 
kind  that  a  pathogenetic  germ  has  been  able  to  make  good  its  position 
in  the  tissues  of  the  patient,  although  in  both  instances  the  organisms 
are  multiplying  rapidly,  and  may  be  producing  their  products  in  con- 
siderable quantities.  This  is  the  period  of  incubation.  It  is  only 
after  these  products  begin  to  exert  their  gross  specific  effect  on  the 
tissues  that  any  symptoms  by  which  a  diagnosis  can  be  made  appear. 
The  effects  produced  vary,  of  course,  with  the  character  of  the  organism, 
the  rapidity  of  its  growth  :  these  determining  within  certain  limits  the 
length  of  the  period  of  incubation  ;  the  habitat  and  nature  of  the  poison 
determining  the  character  of  the  symptoms.  Thus  in  scarlet  fever  the 
organism  apparently  affects  specially  the  tonsils  and  pharynx,  the  skin 
and  the  kidneys,  perhaps  because  the  organisms  invade  the  patient  by 
the  channels  in  the  former  parts,  and  because  of  the  efforts  made  by 
the  skin  and  kidneys  to  excrete  the  poison.  In  the  case  of  typhoid 
fever  the  micro-organisms  appear  to  affect  the  lymphoid  tissue  of  the 
alimentary  tract,  especially  in  the  lower  part  of  the  intestine  ;  the  spleen 
is  also  a  seat  of  election  in  this  condition,  whilst  the  skin  is  only  slightly 
affected. 

As  would  be  expected,  the  initial  dose  of  the  poison  may  exert  some 
influence  in  determining  the  length  of  the  incubation  period.  It  only  a 
small  amount  of  the  poison  be  introduced,  and  this  holds  good,  especially 
in  the  case  of  such  a  disease  as  scarlet  fever,  the  period  of  incubation  may 
be  prolonged  ;  while,  on  the  other  hand,  if  a  very  large  dose  be  absorbed, 
the  period  of  incubation  may  be  very  short.  This  is  due  not  entirely  to  the 
mere  number  of  organisms  introduced  affecting  the  period  through  which 


THE   INFECTIONS  43 

multiplication  must  take  place  to  bring  the  number  up  to  a  certain  point ; 
the  large  number  introduced,  perhaps,  along  with  a  certain  proportion 
of  their  products,  act  upon  the  tissues,  and  render  them  less  resistant,  so 
that  the  organisms  that  have  found  an  entrance  are  enabled  to  multiply 
much  more  rapidly  than  when  the  tissues  are  not  so  prepared.  Of 
course  dififerent  organisms  multiply  and  produce  symptoms  at  very 
dilTerent  rates.  For  this  reason,  and  because  they  form  their  products 
in  different  positions,  and  in  varying  quantities,  marked  differences  are 
observed  in  the  lengths  of  the  incubation  periods  of  different  diseases, 
e.g.  diphtheria  as  compared  with  tuberculosis. 

In  the  really  characteristic  stages  of  a  disease  the  symptoms  are,  as 
a  rule,  the  result  of  the  changes  induced  by  the  action  of  micro-organisms 
on  the  tissues,  and  of  the  tissues  on  the  micro-organisms.  For  instance, 
rigors,  fever,  or  an  apyretic  condition,  rapid  pulse,  increased  rate  of 
respiration,  conjunctival  suffusion,  dilatation  of  the  pupil,  vomiting, 
headache,  muscular  pains,  and  other  ner\-ous  symptoms,  are  attributable 
to  the  action  of  certain  of  the  poisons  produced  by  micro-organisms 
upon  the  thermogenic,  respiratory,  vaso-motor,  pneumogastric,  and  other 
nerve  centres.  The  swelling  of  glands,  pharyngitis,  albuminuria,  and 
the  cutaneous  rashes  occurring  in  certain  exanthematous  diseases,  on 
the  other  hand,  are  due  to  the  reaction  of  the  cells  in  the  glands, 
kidney,  and  skin,  to  certain  others  of  the  poisons  as  they  are  being 
excreted.  Proliferation  and  increased  vascularity  and  joint  pains  result 
from  stimulation  of  the  cells,  ner\es,  and  walls  of  the  blood  vessels  by 
the  toxin,  whilst,  in  such  a  condition  as  typhoid  fever,  the  increase  of 
the  lymphoid  tissue  in  the  enlarged  lymphatic  glands  indicates  a  similar 
process  of  reaction  to  the  specific  stimulation  of  the  typhoid  poison. 

It  is  to  this  specific  reaction,  during  the  course  of  the  febrile  stage, 
that  the  patient  owes  his  chance  of  recovery.  WTien  septic  organisms 
or  the  anthrax  bacillus  are  introduced,  if  no  marked  tissue  reaction  is 
set  up,  the  patient,  whether  brute  or  human,  usually  succumbs  very  rapidly 
to  septic  or  anthrax  poisoning  ;  but  when  local  reaction,  in  the  form  of 
swelling,  redness,  and  oedema  is  marked,  and  especially  where  infiltration 
with  leucocytes  occurs,  the  patient  usually  stands  a  fair  chance  of  recovery. 
It  seems  to  be  a  general  law  that  animal  cells,  when  repeatedly  sub- 
jected to  a  not  too  powerful  specific  stimulation,  have  the  power,  first,  of 
becoming  so  accustomed  to  this  special  stimulation  when  gradually  applied, 
that  they  may  in  time  become  capable  of  carrying  on  their  special  functions, 
even  in  the  presence  of  larger  and  larger  quantities  of  the  stimulating 
substances  ;  and,  second,  of  producing  substances  which,  separable  from 
the  cells,  are  capable  of  directly  neutralising  the  action  of  the  special 
stimulant,  i.e.  a  function  of  the  cell  which,  under  ordinary'  conditions, 
remains  in  abeyance,  or  develops  only  in  a  very  slight  degree,  becomes 
developed  to  such  an  extent  that  it  overflows,  as  it  were,  from  th*^.  cells, 
and  takes  upon  itself  the  special  function  of  so  neutralising  the  toxin  that 


44  MANUAL   OF   MEDICINE 

the  cell  itself  is  enabled  to  carry  on  its  functions  without  being  in  any 
way  hampered  by  the  presence  of  the  toxin.  Every  evidence  of  local 
reaction,  then,  whether  redness  or  local  swelling,  affords  an  indication 
that  this  process  of  "  acclimatisation  "  and  anti-toxin  production  are  going 
on,  and  it  is  only  as  the  cell  becomes  acclimatised  to  the  presence  of  the 
toxin  and  of  the  micro-organisms,  or,  as  the  anti-toxin  is  developed  in 
sufificient  quantities  to  neutralise  the  toxin  already  formed,  or  being 
formed,  that  the  patient  recovers,  or  is  protected  against  future  attacks 
of  the  disease. 

In  typhoid  fever,  where  there  is  a  gradual  increase  in  the  severity  of 
the  disease,  there  is  also,  when  the  patient  recovers,  a  gradual  diminution 
in  the  severity  of  the  disease  symptoms,  this  taking  place  during  the 
period  of  "  lysis."  During  the  rise  of  the  fever  there  is  a  gradual  increase 
in  the  amount  of  toxin  present,  even  though  the  production  of  anti-toxin 
and  the  process  of  accHmatisation  of  the  cells  may  commence  at  a  very 
early  stage  of  the  disease.  After  a  certain  period  the  ratio  between  the 
formation  of  toxin  and  the  production  of  anti-toxin  is  gradually  altered, 
and  during  the  period  of  lysis  the  relative  amount  of  anti-toxin  to  toxin 
rises,  until  ultimately  the  whole  of  the  toxin  is  neutralised,  and  the  period 
of  convalescence  is  then  entered  upon — the  period  during  which  the 
gradual  repair  of  the  damage  done  to  the  tissues  is  commenced.  Anti- 
toxin can  neutralise  the  poison,  but  it  cannot  undo  the  damage  already 
sustained  by  the  tissues — a  damage  which  can  only  be  made  good  by 
the  reparative  action  of  the  tissues  themselves.  In  the  case  of  pneumonia 
the  disease  runs  its  course  much  more  rapidly.  The  period  of  invasion 
and  that  of  fever  are  both  comparatively  short ;  the  production  of  anti- 
toxin appears  to  go  on  very  quickly,  and  recovery  is  very  speedy,  by  a 
"  crisis  "  in  which  there  is  rapid  inversion  of  the  balance  between  the 
toxins  and  the  anti-toxins. 

It  will  thus  be  evident  that  in  ordinary  septicaemias  —  blood 
poisonings — bacteria  make  their  way  from  point  to  point,  carried  by 
the  blood  through  the  blood  vessels,  and  the  symptoms  and  lesions  are 
essentially  those  that  one  would  expect  to  occur  under  such  conditions. 
The  so-called  tissue  parasites,  on  the  other  hand,  appear  to  be  unable 
to  exist  in  the  blood  stream  itself  and  only  when  they  come  to  rest  in 
the  tissues.  In  such  a  condition  as  typhoid  fever,  which  may  be  taken 
as  an  example,  the  parasitic  organisms  are  found  specially  in  the  adenoid 
follicles  of-  the  intestine,  in  the  neighbouring  glands,  and  also  in  the 
spleen,  whither  they  appear  to  make  their  way  from  the  intestine  by 
the  lymphatics.  It  is  probable  that  they  are  not  confined  entirely  to 
the  lymphoid  follicles,  and  that  much  more  widespread  tissue  changes 
are  set  up  than  are  usually  demonstrated.  Typhoid  fever,  then,  cannot 
be  looked  upon  as  an  ordinary  septicaemia,  though,  under  certain  con- 
ditions, the  typhoid  organisms  may  flourish  in  the  blood  ;  it  then  becomes 
truly  septicasmic  in  character. 


THE   INFECTIONS  45 

The  multiplication  of  the  micro-organism,  and  the  formation  of  its 
special  products,  are  the  real  elements  that  determine  the  specific 
character  of  the  disease  ;  and  just  as  specific  fermentations  and  special 
colour  formations  occur,  and  special  gases  are  formed,  so  specific  diseases 
may  be  produced  in  which  the  tissues  and  fluids  of  the  patient  are,  for 
the  time  being,  converted  into  nutrient  media,  in  which  micro-organisms 
can  grow  and  produce  their  special  products,  these  specific  products,  by 
their  action  on  the  reacting  cells  and  tissues,  giving  rise  to  the  specific 
symptoms.  The  body  of  the  patient  difters,  however,  in  one  very  im- 
portant respect  from  any  ordinar}'  nutrient  medium.  The  organisms  in 
the  artificial  nutrient  medium  grow  for  a  time  with  ver}'  great  rapidity, 
and  then  by  the  production  of  organic  acids,  phenols,  etc.,  convert  this 
medium  into  a  fluid  in  which  they  are  incapable  of  further  development. 
These  substances,  however,  must  be  present  in  considerable  quantities, 
and  may  usually  be  detected  by  ordinary  chemical  examination  before  the 
organisms  cease  to  multiply.  In  the  animal  body,  on  the  other  hand, 
such  substances  are  not  formed  in  any  considerable  quantities  ;  or,  at  any 
rate,  not  in  quantities  sufficiently  large  to  interfere  materially  with  the 
growth  of  the  organisms.  Nevertheless,  the  organisms  no  longer  thrive, 
and  the  toxins  they  produce  are  no  longer  capable  of  doing  any  harm. 
This  appears  to  be  due  to  the  fact  that  the  cells  have  formed  anti- 
toxins which  do  not  act  directly  upon  the  organisms,  as  do  the  products 
of  fermentation,  but  only  upon  their  toxins,  with  the  result  that  the 
micro-organisms,  with  their  poisons  neutralised,  are  at  once  reduced  to 
the  level  of  mere  saprophytes  ;  they  are  disarmed  and  fall  a  prey  to  the 
devouring  phagocytes,  which  are  constantly  on  the  alert  for  all  "  foreign  " 
bodies  coming  within  their  sphere  of  influence.  A  patient  thus  recovers 
from  a  specific  infective  fever,  and,  having  suffered  from  one  attack  of  a 
specific  disease,  has  acquired  against  it  a  marked  degree  of  immunity, 
which  may  continue  for  a  very  considerable  period. 

It  is  well  to  bear  in  mind  that  mixed  infections  are  of  somewhat 
frequent  occurrence.  Such  infections  may  be  coincident,  the  organisms 
finding  their  way  to  the  tissues  at  the  same  time  and  helping  one  another 
to  produce  their  special  effects  ;  for  example,  the  tetanus  organism  is 
much  more  to  be  feared  in  the  presence  of  pyogenetic  organisms  than  it 
is  when  acting  alone.  Then  again  the  diphtheria  organism,  when  aided 
by  the  pus-producing  organisms,  is  capable  of  doing  far  more  damage 
than  it  is  alone  ;  whilst  pus-producing  organisms  are  often  enabled  to 
make  their  way  much  more  readily  into  the  deeper  tissues  and  then  to 
set  up  a  pyaemia,  when  they  are  aided  by  the  diphtheria  bacillus  acting 
on  the  mucous  membrane  or  submucous  tissue  of  the  throat.  The 
sequelae  of  the  infective  fevers  are  verj'  frequently  the  result  of  a 
secondary'  infection.  Mixed  infections,  however,  may  occur  from  the 
ver}'  commencement  of  the  disease  ;  the  prognosis  of  such  cases  is 
usually  much  more  hopeless  than  in  the  case  of  the  simple  diseases. 


46  MANUAL  OF   MEDICINE 

Terminations  of  the  Infective  Diseases 

It  is  evident  that  the  acute  infective  disease  must  run  a  rapid  course, 
though  that  of  an  exanthematous  disease  is  more  rapid  than  that  of  a  case 
of  acute  puhnonary  tuberculosis,  which  latter  condition,  however,  should 
be  looked  upon  as  a  chronic  disease  which  runs  a  comparatively  rapid 
course.  Acute  diseases  may  have  one  of  three  terminations.  If  the 
poison  is  rapidly  excreted  and  if  the  degenerative  changes  brought  about 
by  it  are  not  too  profound,  there  may  be  practically  complete  recovery. 
Even  when  the  patient  does  not  succumb,  a  series  of  changes  which,  with- 
out bringing  about  actual  death,  may  so  alter  the  conditions  of  growth, 
secretion,  and  excretion  through  the  intercurrence  of  such  states  as 
chronic  interstitial  nephritis,  catarrhal  nephritis,  chronic  interstitial 
hepatitis  and  similar  lesions,  that  the  health  of  the  patient  is  materially 
interfered  with.  The  nutrition  of  the  muscle  of  the  heart  may  be  so  far 
impaired,  as  in  cases  of  typhoid  fever,  diphtheria,  influenza,  or  the  peripheral 
nerves  or  the  nerve  centres  may  have  been  so  altered  by  the  action  of  the 
poisonous  products  of  the  disease,  that  the  patient  may  die  suddenly 
from  heart  failure  when  he  appears  to  be  well  on  the  road  to  recovery. 
In  the  third  mode  of  termination,  death  may  supervene  during  the  height 
of  the  fever,  the  patient  succumbing  directly  to  the  action  of  the  toxin  on 
the  nerve  centres,  on  the  secretory  glands,  or  on  the  tissues  generally. 

In  the  chronic  infective  disease  the  poison  or  toxin  is  as  a  rule 
more  dilute,  acts  for  a  longer  period,  and  appears  to  affect  the  connective 
tissues,  especially  those  associated  with  excretory  epithelial  surfaces. 
It  may  be  accepted  generally  that  the  more  chronic  the  disease  the  less 
do  the  epithelial  tissues  undergo  rapid  degenerative  changes,  but  the 
more  is  fibrous  tissue  developed  at  those  points  at  which  the  poisonous 
products  are  being  excreted.  For  example,  in  syphilis  and  tuberculosis 
the  formation  of  fibrous  tissue  with  coincident  or  subsequent  degenerative 
changes  is  exceedingly  well  marked,  and  is  comparable  to  the  fibrosis 
of  lead  poisoning  and  chronic  alcoholism.  In  actinomycosis,  where 
less  poison  is  formed,  this  tendency  to  fibrous  tissue  formation  is  more 
distinctly  marked,  and  there  is  far  less  tendency  to  degeneration  even 
than  in  tubercle. 

The  elimination  of  poisonous  products  from  the  body  appears  to 
take  place  by  much  the  same  channels  as  the  normal  effete  matters  the 
result  of  metabolic  processes.  The  diarrhoea  that  accompanies  the  ex- 
hibition of  certain  poisons  can  only  be  compared  to  that  met  with  in 
cholera  and  typhoid  fever  as  an  effort  on  the  part  of  the  intestines  to 
get  rid  of  noxious  material.  The  acute  nephrites  that  occur  during  the 
course  of  scarlet  fever  and  diphtheria  are  examples  of  conditions  com- 
parable to  that  observed  in  mercury  poisoning.  The  skin  also  appears 
to  play  an  important  part  in  getting  rid  of  poisonous  products.  Typhoid 
bacilli  may  be  found  in  the  urine  and  in  the  bile,  and  it  is  probable,  as 


THE   INFECTIONS  47 

pointed  out  by  Sherrington,  that  not  only  the  products  of  micro-organisms, 
but  even  the  micro-organisms  themselves  may  pass  out  through  "  intact" 
mucous  membranes,  especially  in  the  case  of  the  acute  infections. 


Post-mortem  Appearances  common  to  the  Acute  Infections 

In  almost  all  the  febrile  infective  conditions,  certain  general  post- 
mortem appearances  in  the  patient  who  has  succumbed  point  to  the 
nature  of  the  disease.  In  most  cases,  owing  to  the  degenerative  changes 
that  occur  in  the  muscle  before  death,  rigor  tnortis  is  much  less  perfect 
and  passes  off  at  a  much  earlier  period  than  in  patients  who  succumb 
to  other  diseases.  In  many  of  the  fevers,  especially  those  of  a  specific 
and  septic  character,  the  blood  is  so  changed  even  before  death  that  it 
does  not  undergo  coagulation,  the  capillary  vessels  lose  their  tonicity, 
the  blood  flows  through  them  readily  into  the  dependent  parts  of  the 
body,  and  post-mortem  lividity  is  often  very  marked,  the  heart  and 
blood  vessels  and  even  the  skin  being  blood-stained.  In  the  cases  of 
acute  fever  resulting  from  specific  infection,  the  organs  are  usually  in  a 
condition  of  cloudy  swelling  ;  they  are  swollen,  paler  than  normal,  and 
exhibit  a  ven,-  characteristic  parboiled  appearance.  The  spleen  is  usually 
enlarged  and  pulpy,  especially  in  typhus.  The  liver  and  kidneys  at  the 
later  stages  of  the  disease  present,  in  addition  to  this,  evidence  of  fatty 
degeneration,  whilst  in  the  former  organ  distinct  necrotic  areas  of  the 
parenchyma  may  sometimes  be  observed.  In  almost  every  fever  fatty 
degeneration  of  the  heart  of  a  more  or  less  marked  character  occurs 
sometimes  during  the  second  week  of  the  affection,  and  in  certain 
diseases,  such  as  those  already  mentioned — diphtheria,  influenza,  typhoid, 
and  also  in  almost  all  of  the  other  infective  febrile  diseases — this  is  an 
important  clinical  fact  that  is  frequently  ignored  in  the  treatment  of  con- 
valescent patients.  Cardiac  dilatation  is  an  essential  feature  of  acute 
rheumatism,  due  in  part  to  the  degeneration  associated  with  myocarditis, 
and  also,  it  would  appear,  to  a  specific  toxic  effect  directly  affecting  the 
muscles.  The  muscles  usually  participate  in  the  general  changes  of 
cloudy  swelling  and  fatty  degeneration  ;  in  typhoid  and  more  rarely  in 
other  fevers,  Zenker's  hyaline  or  vitreous  degeneration  is  also  met  with. 

Classification 

In  recent  text -books  of  medicine  the  classification  of  specific 
infective  conditions  or  "  infections "  is  based  not  entirely  upon  the 
clinical  symptoms  as  in  the  older  works,  but  partly  upon  the  nature  of 
the  etiological  factor, — bacteria  or  their  products, — though  in  only  a 
certain  number  of  these  infections  has  the  actual  causa  causans  been 
demonstrated. 

Diseases  may  be  endetnic  or  epidemic.      An  endemic  disease  is  one 


48 


MANUAL  OF  MEDICINE 


that  is  constantly  found  in  a  region  in  which  the  "  local "  conditions 
appear  to  be  specially  favourable  to  the  continuance  of  the  existence  of 
the  organism  producing  such  disease.  An  epidemic  disease  is  a  sudden 
outbreak,  either  through  the  conditions  becoming  specially  favourable 
for  the  existence,  multiplication,  and  transmission  of  the  disease-pro- 
ducing organisms  or  of  the  introduction  of  these  organisms  from  the 
region  in  which  the  disease  is  already  endemic.  An  epidemic  outbreak 
may  occur  in  a  locality  in  which  the  disease  is  endemic  ;  it  is  then  due 
to  the  development  and  bringing  into  action  of  special  predisposing 
causes,  which  do  not  usually  exist,  the  epidemic  character  of  the  disease 
depending  greatly  upon  the  facilities  offered  for  its  rapid  spread  amongst 
a  population  specially  prepared  for  its  inroads. 

The  following  classification  of  infections  is  founded  partly  upon  the 
specific  nature  of  the  organisms  present,  partly  upon  the  symptoms  and 
changes  that  result  from  such  actions  and  interactions  : — 


I. 


Febrile  Infective  Diseases  with  which  Micro-organisms 
have  been  definitely  associated 


(A)  Acute    - 


Local 


General   ■< 


f    Boil  and  Carbuncle 
\  ^Erysipelas 

Septicsemia  and  Pyaemia 
Infective  Endocarditis 
*Puerperal  Septic  Fever 
Gonorrhoeal  Infection 

*Typhoid  Fever 

Mediterranean  Fever 
*Cholera 

Plague 
^Relapsing  Fever 

Yellow  Fever 

Weil's  Disease 


(B)  Chronic 


Anthrax 
Tetanus 
*Diphtheria 
Epidemic  Pneumonia 
Infective  Meningitis 
Influenza 
Glanders  (Farcy) 

Tuberculosis 

Leprosy 

Mycoses 


^  Due  to  Pyococci 


Due  to  Specific 
Organisms 


*  These  diseases  must  be  notified  to  the  Medical  Officer  of  Health  of  the  District 
in  which  the  case  occurs,  according  to  the  provisions  of  the  Infectious  Diseases 
Act,  1889,  Sect.  3. 


THE   IXFECTIOXS 


49 


II.    Febrile  Infective  Diseases  with  which  Micro-organisms 

HAVE    NOT    YET    BEEN    DEFINITELY    ASSOCIATED 


[  *Typhus 

Measles 

Rotheln 
*Scarlet  Fever 

Acute  Rheumatism 

Chicken-pox 
*Smallpox 

Vaccinia  (Cattle) 

Mumps 

Whooping  Cough 


Acute  and  Chronic 


Dengue 
Beri-Beri 
Epidemic  Dropsy 
Oriental  Sore 
Verrugas 
Fraraboesia 

Syphilis 

Rabies 

Foot  and  Mouth  Disease  (Cattle) 

Mixed  Infections 


III.   Febrile  Infective  Diseases  due  to  Protozoa 

Dysentery 
Malaria 

Hsemoglobinuric  Fever 
Kala-azar 

*  These  diseases  must  be  notified  to  the  Medical  Officer  of  Health  of  the  District 
in  which  the  case  occurs,  according  to  the  pro\-isions  of  the  Infectious  Diseases  Act, 
1889,  Sect.  3. 

G.  Sims  Woodhead. 


vol.  I 


5° 


MANUAL  OF  MEDICINE 


FEVER 


The  word  fever  is  employed  to  designate  a  certain  assemblage  of 
symptoms.  These  are  a  rise  of  the  internal  temperature  of  the  body 
(pyrexia),  a  quickened  pulse,  rapid  respiration,  loss  of  appetite,  malaise, 
furred  tongue,  scanty,  high-coloured  urine,  often  containing  a  trace  of 
albumen,  and,  allowance  being  made  for  the  diet,  an  excess  of  urea, 
constipation,  a  flushed  skin,  sweating,  headache  and  delirium.  It  is  by 
no  means  necessary  that  all  these  symptoms  should  be  present  in  the 
same  person  for  us  to  say  he  has  fever,  and  in  the  above  list  the  symp- 
toms are  roughly  placed  in  their  order  of  frequency.  Pyrexia  is,  how- 
ever, constant,  and  a  patient  cannot  be  said  to  have  fever  unless  it 
exists.  How  far  the  other  symptoms  are  the  result  of  the  pyrexia,  or 
the  result  of  the  cause  of  the  pyrexia,  is  at  present  undetermined,  but 
many  are  certainly  at  times  merely  dependent  upon  the  temperature,  and 
therefore  the  terms  fever  and  pyrexia  are  occasionally  loosely  used  as 
though  they  were  interchangeable  ;  this  is  inexact  and  to  be  deprecated, 
but  as  pyrexia  is  the  only  constant  sign  of  fever,  and  has  been  more 
studied  than  any  other  sign,  in  describing  fever  it  is  the  pyrexia  to 
which  reference  will  chiefly  be  made.  In  this  article  the  slight  rises  of 
temperature  which  follow  exercise  and  may  be  considered  physiological 
will  not  be  considered. 

The  internal  temperature  of  the  human  body  may  be  taken  in  the 
rectum,  the  vagina,  the  stream  of  urine  as  it  issues  from  the  bladder, 
the  axilla  or  the  mouth  :  the  two  first  situations  give  the  most 
accurate  results.  The  mean  daily  rectal  temperature  of  a  healthy  adult 
is  98.96°  F.,  that  of  the  stream  of  urine  is  98.56°  F.,  that  of  the  axilla 
is  98.45°  F.,  and  that  of  the  mouth  is  98.36°  F.,  and  in  each  of  these 
cases  the  temperature  in  health  may  be  half  a  degree  Fahrenheit 
below  the  figure  given  in  the  early  morning,  and  half  a  degree  above  the 
figure  given  in  the  evening  between  6  and  7  P.M.  It  is  more  important 
that  the  temperature  should  be  taken  carefully  with  an  accurate  thermo- 
meter, than  that  any  particular  site  for  observing  it  should  be  chosen. 
Mistakes  most  readily  occur  in  the  mouth  from  not  keeping  it  shut,  not 
keeping  the  thermometer  under  the  tongue,  and  not  noticing  whether 
the  mouth  has  been  recently  locally  heated  or  cooled ;  and  in  the  axilla 
from  not  keeping  the  thermometer  well  in  position.  The  grom  is  an 
excellent  situation  for  taking  the  temperature  of  children.  The  healthy 
temperature  of  different  adults  diff'ers  slightly,  but  only  a  fraction  of 
degree,  for  one  of  the  striking  characteristics  of  the  higher  warm- 
blooded animals  is  the  uniformity  of  the  temperature  of  different  adult 
individuals  of  th"  same  species.     With  children  this  power  of  maintain- 


FEVER  5 I 

ing  a  fixed  temperature  is  not  so  striking.  The  foetus  in  the  early 
months  of  intrauterine  life  is  cold-blooded,  and  it  is  only  gradually  that 
the  individual  acquires  the  power  of  so  controlling  the  balance  between 
loss  and  production  of  heat  that  the  temperature  is  constant.  Therefore 
in  children  slight  causes,  which  would  in  an  adult  be  inoperative,  may 
cause  considerable  pyrexia,  perhaps  without  other  signs  of  fever  ;  even 
simple  constipation  may  cause  the  temperature  to  rise  to  104°  F. 
Hence  it  is  that  pyrexia  is  often  less  alarming  in  children  than  in  adults. 

It  is  conceivable  that  the  temperature  of  the  body  might  rise  because, 
other  things  being  equal,  its  specific  heat  decreased,  but  there  is  no 
evidence  that  this  ever  occurs. 

The  temperature  remains  nearly  constant  in  health,  because  the 
production  of  heat  which  takes  place  chiefly  in  the  muscles  is  exactly 
counterbalanced  by  the  loss  which  takes  place  chiefly  from  the  skin  by 
radiation,  and  by  evaporation  of  sweat,  and  the  fundamental  problem 
in  the  study  of  any  case  of  pyrexia  is,  whether  the  temperature  has 
risen  because  the  loss  of  heat  has  diminished  while  the  production 
remains  the  same,  or  whether  the  production  has  increased,  the  loss 
being  unaltered,  or,  lastly,  whether  both  production  and  loss  having 
varied  the  temperature  has  risen  because  the  two  classes  of  variations 
have  not  counterbalanced  each  other. 

Three  chief  methods  have  been  employed  in  attacking  this  problem, 
{a)  the  calorimetric  ;  (1^)  the  chemical  ;  and  (1;)  the  clinical  ;  and  full 
accounts  of  each  will  be  found  in  my  Croonian  lectures  on  "  The  Means 
by  which  the  Temperature  of  the  Body  is  maintained  in  Health  and 
Disease,"  1897.  The  calorimetric  is  so  complicated  and  so  full  of 
fallacies  that  it  cannot  be  described  here,  and  the  chemical,  which  has 
yielded  some  most  important  results,  is  very  difficult  to  apply  at  the  bed- 
side, but  its  results  show  that  in  animals  some  fevers  are  certainly 
accompanied  by  a  considerable  increased  production  of  heat.  Probably 
we  must  be  especially  cautious  in  applying  to  man  conclusions  about 
fever  arrived  at  by  experiments  on  animals,  for  as  many  of  them  do  not 
sweat  and  have  thick  fur,  their  loss  of  heat  must  differ  from  that  of 
man.  The  method  which  I  have  called  the  clinical  depends  upon  the 
following  considerations.  It  is  clear  that  when  the  surface  temperature 
of  the  body  rises  the  loss  of  heat  by  radiation  and  conduction  will  be 
increased,  and  that  when  the  amount  of  sweat  secreted  is  increased, 
the  loss  of  heat  from  evaporation  is  increased,  so  that  if  in  any  case 
it  can  be  shown  that  the  internal  temperature  has  risen  and  at 
the  same  time  the  surface  temperature  has  risen  and  the  amount  of 
sweat  secreted  has  increased,  the  production  of  heat  must  have  in- 
creased, provided  that  the  temperature  of  the  surrounding  air  is 
constant,  and  in  the  wards  of  a  hospital  it  is  kept  nearly  so.  The 
internal  temperature  is  registered  with  an  ordinary  accurate  clinical 
thermometer,  and  the  surface  temperature   is   taken   with    special   flat 


52  MANUAL  OF  MEDICINE 

bulbed  thermometers.  The  sweat  is  estimated  by  using  calcium  chloride 
as  an  absorbent.  It  is  fused  into  the  bottom  of  a  glass  box  which 
has  an  air-tight  lid  ;  the  box  and  its  lid  are  weighed  ;  the  box  with  its 
lid  off  is  then  inverted  at  a  given  spot  on  the  skin  for  a  given  time,  the 
lid  is  at  once  put  on,  the  box  is  again  weighed,  and  the  gain  in  weight 
represents  the  amount  of  sweat  absorbed.  There  are  many  small  details 
to  be  attended  to  which  I  described  elsewhere.  A  series  of  observations 
are  made  on  the  patient  when  his  temperature  is  raised,  and  another 
series  when  he  is  well  and  his  temperature  has  become  normal.  A 
comparison  will  show  whether,  when  the  temperature  was  raised,  the  loss 
of  heat  by  radiation  and  evaporation  was  more  or  less  during  fever  than 
during  health.  If  it  was  more  the  production  of  heat  must  have  been 
enormously  increased  during  the  febrile  period,  for  not  only  was  the 
internal  temperature  raised,  but  the  loss  of  heat  was  greater.  But  if  it 
was  less  it  must  have  been  that  some  at  least  of  the  rise  of  internal 
temperature  was  due  to  a  diminution  in  the  loss  of  heat.  A  series  of 
observations  carried  out  by  this  method  showed  that  in  typhoid  fever  the 
pyrexia  was  largely  due  to  a  lessened  loss  of  heat,  that  in  pneumonia 
there  is  a  very  considerable  increased  production  of  heat,  that  in 
erysipelas  there  is  also  an  increased  production  of  heat,  and  that  in 
suppuration  there  is  a  diminution  in  the  loss  of  heat.  These  results 
show  that  sometimes  the  pyrexia  of  fever  is  due  to  an  increased  pro- 
duction of  heat,  and  that  sometimes  it  is  due  to  a  diminution  of  the  loss, 
that  is  to  say  that  different  toxins  produce  fever  in  different  ways.  This 
is  a  different  view  from  that  of  some  older  writers,  who  endeavoured  to 
explain  all  fever  by  the  same  process. 

It  is  interesting  to  note  that  typhoid  fever,  although  a  long-lasting 
disease  with  a  high  temperature,  has  a  low  mortality  ;  the  reason  for  this 
may  be  that,  as  the  loss  of  heat  is  diminished,  the  temperature  is  raised 
with  the  least  expenditure  of  energy,  and  it  is  also  interesting  to  observe 
that  experience  has  shown  that  the  best  way  to  reduce  pyrexia  in  typhoid 
fever  is  by  the  external  application  of  cold  water,  that  is  by  increasing 
the  loss  of  heat.  On  the  other  hand,  pneumonia  is  a  disease  in  which 
the  pyrexia  lasts  but  a  little  while  compared  with  typhoid  fever ;  as  it  is 
due  to  an  increased  production  of  heat  the  patient  could  hardly  survive 
a  long-continued  fever  accompanied  by  such  a  loss  of  energy. 

Pyrexia  occurs  chnically  either  (i.)  as  a  result  of  disease  or  damage  of 
the  central  nervous  system,  e.g.  that  which  follows  haemorrhage  into  the 
pons  or  (ii.)  as  a  result  of  the  introduction  of  a  poison  into  the  body,  e.g. 
the  pyrexia  produced  by  atropine  poisoning  or  that  of  the  specific  fevers 
in  some  of  which,  e.g.  diphtheria,  the  toxin  which  causes  the  pyrexia  has 
been  isolated.  Cases  often  occur,  especially  in  children,  in  which  the 
only  evidence  of  toxaemia  is  pyrexia  and  other  febrile  symptoms  ;  usually, 
however,  there  are  other  associated  phenomena,  e.g.  the  rash  of  scarlet 
fever,  the  physical  signs  of  pneumonia,  the  inflammation  of  the  joints  in 


FEVER  53 

rheumatic  fever,  by  which  we  can  distinguish  the  disease,  and  some- 
times, as  in  the  case  of  diphtheria,  malaria,  or  tubercle,  recognise  the 
micro-organism  which,  by  its  power  of  manufacturing  toxins,  causes  the 
febrile  symptoms. 

(i.)  That  damage  to  the  central  nervous  system  will  cause  pyrexia  has 
been  shown  chiefly  by  experiments  upon  the  corpus  striatum  and  spinal 
cord.  I  have  published  twenty-seven  experiments  in  which  the  corpus 
striatum  of  rabbits  was  experimentally  damaged.  The  rise  of  the  rectal 
temperature  was  sometimes  over  4°  or  5°  F.,  and  the  average  rise  was 
2.74°  F.  This  was  always  after  a  unilateral  lesion,  and  the  pyrexia 
never  lasted  more  than  a  day  or  two. 

In  clinical  medicine  lesions  in  the  following  positions  will  cause 
pyrexia.  (Full  references  will  be  found  in  an  article  in  the  Brit.  Med. 
Jour)ial.,  Nov.   17,  1894.) 

(A)  Cortex. — Dr.  J.  H.  Bryant  has  shown  that  out  of  a  hundred  cases 
of  hyperpyrexia  {i.e.  temperature  over  106°  F.),  in  eight  it  was  due  to  injury 
of  the  cerebral  cortex.  Usually  there  was  also  meningeal  hcemorrhage, 
but  in  one  there  was  only  laceration  of  the  cortex.  The  temperatures 
were  109'',  108.4',  107.8",  107.4",  ^o?')  loj  j  lo?',  and  106.6°,  and  it 
is  by  no  means  uncommon  to  meet  with  pyrexia  after  lesions  of  the  cortex. 

(B)  Corpus  striatum.  —  So  many  cases  have  been  referred  to  by 
myself  and  others,  that  it  is  now  known  that  haemorrhage  into  the 
corpus  striatum  is  frequently  followed  by  pyrexia,  unless  the  excessive 
loss  of  blood  keeps  the  temperature  down.  The  rise  may  be  as  high 
as  108"  F.  If  only  one  corpus  striatum  is  damaged  the  rise  of  tempera- 
ture is  often  higher  in  the  a.xilla  of  the  paralysed  limb,  that  is  to  say 
the  one  opposite  the  lesion,  than  in  that  on  the  sound  side.  By  com- 
paring the  variations  in  the  loss  of  heat  on  the  two  sides  of  the  body  I 
have  been  able  to  show  that  the  loss  is  greater  on  the  paralysed  side  ; 
therefore,  as  the  axillarj'  internal  temperature  is  raised  on  this  side,  it 
follows  that  the  production  of  heat  is  increased  on  the  paralysed  side,  so 
that  in  this  form  at  least  of  cerebral  pyrexia  the  production  of  heat  is 
increased.  The  usual  course  of  the  axillary  temperature  after  an  ordinar}' 
cerebral  hsemorrhage  implicating  the  corpus  striatum  is  that  for  the  first 
few  hours  there  may  be  a  fall  below  normal,  owing  to  the  shock  and  loss 
of  blood,  but  as  the  effects  of  this  pass  off  the  rise  shows  itself.  The 
maximum  is  usually  reached  within  twenty-four  hours.  The  temperature 
then  slowly  falls,  the  normal  point  being  reached  in  a  few  days.  After 
this  it  generally  falls  a  degree  or  so  below  normal,  and  remains  subnormal 
for  a  few  days  before  attaining  the  healthy  standard.  When  it  is  sub- 
normal it  is  still  a  little  higher  on  the  side  opposite  to  a  unilateral  lesion. 
Other  lesions  of  the  corpus  striatum  will  produce  pyrexia. 

(C)  Crura. — Lesions  of  these  may  cause  a  rise  of  temperature  ;  for 
instance  a  case  is  recorded  in  which  a  tumour  pressed  on  the  crus,  and 
a  temperature  of  107.4'  was  reached. 


54  MANUAL  OF   MEDICINE 

(D)  Pons — (E)  Spinal  cord. — It  is  so  well  known  that  damage  to 
these  structures  will  cause  pyrexia  that  it  is  hardly  necessary  to  quote 
cases. 

Therefore  it  appears  that  fibres  proceed  from  the  cerebrum,  probably 
the  corpora  striata,  and  pass  down  by  way  of  the  crura,  pons  and  cord  to 
the  muscles  to  influence  their  thermogenetic  function.  The  cortex  too 
clearly  has  some  influence  ;  how  it  acts  we  hardly  know  ;  it  may  be  that 
it  influences  the  corpus  striatum,  or  that  there  are  thermic  fibres  pro- 
ceeding directly  from  the  cortex.  It  must  be  remembered  that  the 
mechanism  by  which  heat  is  lost  is  also  under  the  control  of  the  central 
nervous  system,  but  the  observations  just  quoted  upon  the  temperature 
in  hemiplegia,  the  absence  of  any  visible  diminution  in  the  radiating  and 
evaporating  power  of  the  skin  even  in  some  cases  of  hyperpyrexia, 
and  the  very  suddenness  and  great  extent  of  the  rise  in  some  cases  of 
damage  to  the  central  nervous  system  all  point  to  the  fact  that,  in  some 
cases  at  least,  the  pyrexia  that  follows  it  is  due  to  an  increased  thermo- 
genesis. 

After  what  has  been  said  the  reader  will  hardly  be  surprised  to  hear 
that  sometimes  the  temperature  rises  in  cases  o{  fimctioiial  disease  of  the 
central  nervous  system.  Occasionally  severe  epileptic  fits  may  be 
followed  by  pyrexia.  A  temperature  of  109°  has  been  recorded,  and 
pyrexia  may  be  observed  in  the  status  epilepticus.  Delirium  tremens 
too  may  have  pyrexia  as  a  symptom  ;  it  has  been  observed  in  severe 
chorea  and  it  may  undoubtedly  be  a  symptom  of  hysteria,  but  the 
diagnosis  of  hysterical  pyrexia  should  only  be  made  after  several 
thorough  examinations,  after  observation  for  at  least  a  fortnight,  and 
after  every  other  possible  cause  for  the  pyrexia  has  been  excluded,  for 
certain  specific  fevers,  especially  typhoid  fever  and  tuberculosis,  are  very 
liable  to  mislead. 

The  central  nervous  system  is  more  often  damaged  in  cases  of  hyper- 
pyrexia than  in  cases  of  pyrexia,  for  Dr.  Bryant  has  shown  that  out  of  a 
hundred  consecutive  cases  in  which  the  temperature  rose  over  106°, 
eleven  were  due  to  injury  to  the  brain,  three  to  cerebral  tumour  or 
haemorrhage,  six  to  injury  to  the  spinal  cord,  and  one  to  myelitis,  in  all 
21  per  cent,  and  hyperpyrexia  occurred  in  2.18  per  cent  of  all 
cases  of  fractured  skull.  The  hyperpyrexia  of  meningitis  (it  occurs 
in  3.4  per  cent  of  all  cases  of  meningitis)  may  be  partly  due  to  direct 
injury  to  the  central  nervous  system.  It  may  be  well  here  to  remind 
the  reader  that  hyperpyrexia  is  most  common  in  the  hottest  months  of  the 
year.  Out  of  Byrant's  hundred  cases  twenty  occurred  in  August  and  fifty- 
one  in  the  months  of  June,  July,  August,  and  September.  But  this  is 
not  surprising,  for  it  is  then  that  the  central  nervous  system  has  greatest 
work,  even  in  health,  in  adjusting  the  production  of  heat  to  the  loss. 

Many  writers  have  thought  that  the  pyrexia  which  follows  severe 
peripheral  irritation,   viz.  that  which  occurs  during  gallstone  colic,    or 


FEVER  55 

that  of  catheter  fever,  is  due  to  the  action  on  the  central  nervous  system 
of  the  strong  peripheral  impulse. 

(ii.)  The  second  variety  of  pyrexia,  that  which  results  from  the  intro- 
duction of  a  poison  into  the  body,  acts  through  the  circulation  carrying 
the  poison  either  to  the  parts  of  the  body  connected  with  the  production 
of  heat  or  to  those  connected  with  the  loss.  The  most  active  known 
pyrexial-producing  poison  is  B.  tetrahydronaphthylamine  ;  I  have  seen 
the  injection  of  it  subcutaneously  into  a  rabbit  cause  a  rise  of  io°  F.  in 
one  and  three-quarter  hours.  But,  as  already  mentioned,  the  most 
interesting  cHnically  of  the  fever-producing  agents  are  micro-organisms 
and  the  toxins  they  manufacture. 

Much  attention  has  been  directed  to  the  question  whether  the 
pyrexia  in  these  cases  is  beneficial  to  the  sufferer,  and  it  is  obvious  that 
this  question  is  of  the  highest  importance.  Some  micro-organisms, 
which  are  very  harmful  to  the  human  body,  have  their  activity  much 
lowered  by  a  temperature  not  very  greatly  in  excess  of  that  of  health ; 
thus  Koch  found  that  if  tubercle  bacilli  were  kept  at  a  temperature  of 
107.5°  F.  for  three  weeks  their  development  was  much  hindered,  whilst 
the  best  temperature  for  them  was  99.5°  F.  Parallel  observations  have 
been  made  upon  the  pneumococcus  and  the  spirillum  of  relapsing  fever. 
Pasteur  and  Wagner  observed  that  fowls,  ordinarily  refractive  against 
anthrax  bacilli,  succumbed  if  their  temperature  was  artificially  lowered. 
On  the  other  hand,  other  observers  have  shown  that  animals  artificially 
warmed  seemed  able  better  to  withstand  certain  specific  fevers.  Loewy 
and  Richter  state  that  rabbits  whose  temperature  is  raised  by  damage  to 
their  corpora  striata  are  the  better  able  to  resist  diphtheria,  fowl  cholera, 
swine  erysipelas,  and  pneumonia.  These  observations,  although  not 
proving  that  the  production  of  pyrexia  is  a  protective  mechanism,  certainly 
suggest  that  it  is,  and  the  fact  that  antipyrin,  acetanilide,  phenacetin,  and 
other  antipyretic  drugs  have  not  been  found  in  any  way  to  benefit  fevers, 
though  possibly  lowering  the  temperature,  points  in  the  same  direction. 
It  is  true  that  ague  is  benefited  by  quinine,  and  rheumatic  fever  by 
salicylates,  but  these  drugs  are  not  of  use  because  they  are  antipyretic, 
but  because  they  are  direct  poisons  to  the  cause  of  the  disease.  Typhoid 
fever  is  certainly  benefited  by  the  reduction  of  fever  by  cold,  but  there 
may  be  a  special  reason  for  this.  Of  course,  it  does  not  follow  from 
this  view  (that  the  production  of  pyrexia  is  a  protective  mechanism) 
that  the  higher  the  temperature  of  the  body  the  better  the  prognosis,  for 
the  higher  temperature  might  be  taken  to  indicate  that  the  dose  of  in- 
fection was  very  severe,  and  that  therefore  the  body  did  all  it  could  to 
resist  the  invasion,  nor  would  it  follow  that  if  the  temperature  did  not 
rise  much  the  dose  of  infection  was  slight,  for  it  might  be  that  the  body 
was  feeble,  and  had  but  httle  power  of  raising  its  temperature  and  there- 
fore defending  itself 

Much  attention  has   been  directed  to  the  disorder  of  nutrition  in 


56  MANUAL  OF  MEDICINE 

fever.  Some  attempts  have  been  made  to  find  out  whether  the  amount 
of  CO2  exhaled  during  specific  fevers  is  increased.  Many  more  ob- 
servations will  have  to  be  made  on  different  fevers  before  the  results  can 
be  accepted  as  final,  but  so  far  as  they  go  they  show  that  in  man  the 
amount  of  COg  excreted  during  fever  is  not  increased.  Thus  Loewy, 
experimenting  on  a  patient  suffering  from  typhoid  fever,  found  that 
when  the  temperature  was  raised  the  output  of  COg  in  cubic  centimetres 
per  minute  was  on  different  occasions  183,  221,  190,  205,  198,  248. 
Three  weeks  later,  when  the  temperature  was  normal,  the  output  was 
277.  The  balance  of  evidence,  too,  is  that  in  fever  the  respiratory 
quotient  is  unaltered. 

Here,  in  passing,  I  should  like  to  call  attention  to  the  fact  that  Mr. 
Hopkins  and  I  found  that  there  was  also  no  increased  excretion  of  COg 
when  the  temperature  was  raised  by  lesions  of  the  corpus  striatum  ;  on 
the  other  hand.  Dr.  Pembrey  and  I  found  that  when  the  temperature  rose 
coincident  with  the  awakening  of  a  hybernating  dormouse,  there  was  an 
enormous  increase  in  the  output  of  CO,.  This  goes  to  confirm  the  view 
that  the  metabolic  processes  of  fever  are  not  merely  an  exaggeration  of 
normal  processes,  but  of  a  different  nature,  and  if  this  view  should 
prove  to  be  true  it  is  of  primary  importance  in  the  consideration 
of  fever. 

The  discharge  of  nitrogen  by  the  kidneys  in  fever  has  long 
been  known  to  be  greater  than  it  would  be  in  health  on  the  same 
diet.  This,  of  course,  points  to  an  increased  destruction  of  proteid 
tissues  ;  in  itself  it  does  not  necessarily  show  that  the  increased  proteid 
katabolism  leads  to  a  total  greater  production  of  heat,  for  there  may  be 
a  lessened  katabolism  of  fats.  May  has,  however,  recently  worked 
out  the  subject  most  thoroughly  in  the  case  of  rabbits  affected  with 
swine  erysipelas.  It  will  be  remembered  that  the  complete  burning  of 
a  gramme  of  albumen  liberates  5550  gramme  calories  (centigrade),  but 
in  our  bodies  albumen  is  only  broken  down  as  far  as  urea,  and  a  gramme 
of  albumen  broken  down  thus  far  yields  about  4000  gramme  calories. 
The  energy-yielding  power  of  a  gramme  of  fat  is  about  9500,  and  that 
of  a  gramme  of  carbohydrates  about  4000  gramme  calories.  If  we 
know  the  amount  of  nitrogen  and  carbon  excreted  by  an  animal,  we 
can  calculate  back  what  must  have  been  the  amounts  of  proteid  and 
fat  to  produce  these  quantities  of  carbon  and  nitrogen,  and  then  we  see 
how  much  energy  this  breaking  down  must  have  yielded.  We  can 
compare  results  if  the  animals  are  kept  quiet  in  a  cage,  and  the  energy 
of  the  cardiac  and  respiratory  muscular  contractions  need  not  be 
considered,  for  that  chiefly  becomes  heat  as  it  has  to  overcome  friction. 
Working  on  these  hnes.  May  has  shown  that  when  a  starving  rabbit's 
temperature  is  raised  by  swine  erysipelas,  there  is  an  increased  katabolism 
which  falls  exclusively  on  the  proteid  tissues,  and  represents  an  increase 
of  about  30  per  cent  in  the   liberation  of  gramme  calories.      The  fat 


FEVER  57 

metabolism  is  unaltered,  therefore  we  learn  that  there  is  in  these 
animals  an  increased  production  of  heat  in  swine  erysipelas  due  to  an 
excessive  destruction  of  proteid. 

Appearances  after  death. — The  cells  of  the  tissues,  especially 
the  muscles  and  glands,  are  after  death  often  cloudy,  somewhat  swollen, 
and  appear  to  have  undergone  parenchymatous  degeneration.  The 
heart  may  be  dilated,  and  this  has  been  ascribed  to  degeneration  of  the 
cardiac  muscle.  The  spleen  is  frequently  enlarged  and  soft,  the  blood 
may  be  imperfectly  coagulated,  and  sometimes  post-mortem  staining  of 
the  heart  and  large  arteries  is  very  evident.  But  any  or  all  of  these 
changes  may  be  absent,  and  we  know  nothing  of  their  cause  ;  some- 
times it  would  appear  that  they  are  due  to  the  direct  action  of  the 
microbic  poisons  on  the  tissues. 

Treatment  of  fever. — Unless  the  pyrexia  is  very  trifling,  the 
patient  must  remain  in  bed.  He  should  have  milk  and  light  farinaceous 
foods,  partly  because  his  powers  of  digestion  are  very  impaired,  and 
partly  because  May  has  shown  that  the  administration  of  carbohydrates 
most  markedly  saves  the  destruction  of  proteid  tissues.  The  quantity 
will  depend  upon  his  power  of  taking  food,  but  all  fevered  patients 
require  as  much  as  they  can  take  without  upsetting  them,  therefore 
meals  should  be  very  frequent  but  small,  and  it  should  never  be  for- 
gotten that  Dr.  Todd  has  made  himself  immortal  because  he  "  fed 
fevers."  Constipation  often  requires  relieving  by  some  mild  aperient, 
and  sleeplessness  may  necessitate  giving  a  hypnotic,  and  as  a  general 
rule  opium  is  the  best.  Barley  water  and  lemonade  or  imperial  drink 
(acid  tartrate  of  potassium  60  grs.,  gluside  i  gr.,  oil  of  lemon  3  m., 
water  i  pint)  often  relieve  the  distressing  thirst  of  fever. 

The  sickroom  should  be  light,  airy  and  quiet.  Its  temperature 
should  be  about  55°  to  60°  F.,  and  whenever  possible  the  windows 
should  be  open. 

If  any  drugs  are  required  they  will  be  mentioned  in  the  description 
of  each  fever.  Those,  such  as  antimony  and  aconite,  formerly  given 
with  the  object  of  reducing  the  pulse,  should  never  be  ordered,  and 
antipyretic  drugs  do  harm. 

Whatever  the  fever,  if  the  temperature  be  so  high  as  in  itself  to  be 
dangerous  to  the  life  of  the  patient,  the  condition  is  called  hyperpyrexia, 
and  usually  this  term  is  applied  to  any  temperature  over  106°  F. 
The  prognosis  is  then  very  grave  ;  84  per  cent  of  all  patients  whose 
temperature  exceeds  106°  die,  and  unless  the  patient  is  obviously  at  his 
last  gasp  cold  must  be  applied  promptly  and  resolutely.  Occasionally 
in  children,  in  whom  the  temperature  fluctuates  easily,  cold  sponging 
may  suffice.  For  instance,  a  child  aged  five  was  under  my  care  for 
pneumonia  ;  the  temperature  was  often  between  104°  and  105°,  and  on 
one  occasion  106.4°.  Under  treatment  by  cold  sponging  and  ice 
poultices  the  patient   recovered.      But  in  nearly  all  cases  a  cold  bath 


58  MANUAL  OF  MEDICINE 

must  be  employed.  For  an  adult,  whose  temperature  is  over  io6°, 
that  of  the  bath  should  be  between  70°  and  75°  ;  for  children  it  may  be 
a  little  higher.  The  patient  should  be  lifted  into  it  in  a  sheet.  The 
water  should  be  stirred,  and  when  the  rectal  temperature  is  100°  or 
101°  he  should  be  taken  out  and  put  back  to  bed  with  a  sheet  over  him. 
The  usual  duration  of  the  immersion  is  ten  minutes,  but  it  is  often  longer. 
If  he  is  collapsed  after  the  bath,  hot-water  bottles  and  strong  brandy 
and  water  are  necessary.  In  private  practice  a  cold  bath  may  be 
improvised  by  putting  a  large  mackintosh  sheet  under  the  patient, 
banking  it  up  with  pillows  so  that  he  lies  in  a  trough,  raising  the  head 
end  of  the  bedstead,  and  pouring  cold  water  in  at  the  head  of  the  trough, 
and  letting  it  run  out  at  the  foot  into  a  pail.  For  hyperpyrexia  the 
cold  bath,  unless  the  shock  of  it  is  too  severe,  is  much  more  efficacious 
than  the  tepid  bath  (90-95°  F.)  gradually  cooled. 

W.  Hale  White. 


BOIL   AND    CARBUNCLE  59 


BOIL    AND    CARBUNCLE 

Pathology.  —  Formerly  boil  ('furuncle)  and  carbuncle  were 
described  separately,  but  it  is  no  longer  necessar}',  since  they  are 
similar  affections,  arising  from  the  same  causes,  and  differing  merely 
in  degree.  All  intermediate  stages  may  be  seen,  from  the  simple 
boil  to  the  difluse  and  destructive  carbuncle.  The  exciting  cause 
in  all  cases  is  the  staphylococcus  pyogenes  aureus.  If  the  inflammatory 
and  necrotic  changes  remain  localised  to  a  hair  papilla  and  its 
sebaceous  glands  a  boil  results,  but  if  they  extend  widely  to  the 
neighbouring  cellular  tissue  and  cause  it  to  die  en  masse  a  carbuncle 
follows.  In  1880  Pasteur  showed  the  existence  of  a  microbe  in 
boils  which  he  believed  to  be  identical  with  that  found  in  osteo- 
myelitis, and  his  obser\-ations  were  confirmed  by  Ogston  and 
others.  It  is  an  interesting  clinical  fact  that  patients  the  subjects 
of  acute  osteomyelitis  have  often  had  at  some  previous  period  a 
crop  of  boils.  Such  also  may  be  experimentally  produced  by 
rubbing  the  skin,  on  the  back  of  the  forearm  for  example,  with 
osteomyelitic  pus.  In  some  cases,  if  the  local  infections  become 
confluent,  a  carbuncle  results.  Some  stress  has  been  laid  on  the 
fact  that  if  in  acute  osteomyelitis  the  infection  be  of  a  mixed 
nature,  i.e.  if  streptococci  as  well  as  staphylococci  are  found,  the 
disease  is  more  intense,  and  it  is  possible,  but  not  yet  clearly 
proven,  that  such  is  the  case  in  carbuncle  of  the  diffuse  variety, 
which  often  runs  a  fatal  course. 

It  is,  therefore,  evident  that  the  clinical  distinctions  made 
between  bofls  and  carbuncles  as  to  shape,  size,  and  the  number  of 
openings,  have  lost  their  significance,  except  the  fact  that  the  area 
of  inflammation  indicates  the  extent  of  subcutaneous  tissue  in- 
volved, and  therefore  the  gravity  of  the  affection. 

There  are  certain  etiological  points  of  interest  and  importance 
in  addition  to  the  rok  played  by  the  staphylococcus  pyogenes  aureus. 
Both  boil  and  carbuncle  are  more  common  in  the  male  sex,  and 
affect  regions  where  the  pilo-sebaceous  follicles  are  most  numerous 
and  have  large  orifices.  Such  regions  are  the  back  of  the  neck, 
the  back,  the  gluteal  region,  the  perinseum,  the  axillae,  and  the 
dorsal  aspect  of  the  first  phalanges  of  the  fingers.  Boils  are  often 
seen  on  the  face  in  the  male  sex,  and  if  on  the  upper  lip  and  of 
large  size  may  develop  into  facial  carbuncle.     It  is  a  curious  fact, 


6o  MANUAL  OF   MEDICINE 

however,  that  carbuncle  is  occasionally  seen  on  the  palms  of  the 
hands  and  soles  of  the  feet,  which  are  quite  hairless,  but  have 
large,  widely  open,  sudoriferous  glands.  In  some  occupations  boils 
are  common  :  thus  cavalry  soldiers  and  rowing  men  are  prone  to 
furunculosis  on  the  gluteal  region  ;  infantry  men  to  boils  on  the 
neck  from  the  rubbing  of  the  stiff  "  stock " ;  tanners  and  post- 
mortem attendants  on  the  backs  of  the  hands.  In  the  case  of  the 
first  two  the  staphylococci  are  present  in  the  clothes,  and  are 
rubbed  into  the  pilo-sebaceous  follicles  by  constant  friction.  Indi- 
vidual liability  is  well  marked.  One  man  will  suffer  if  he  eat  too 
much  meat,  another  if  he  eat  too  little,  while  a  third  may  indulge 
in  all  vagaries  of  diet  and  not  have  a  single  boil.  In  others,  a 
dyspeptic  attack  or  prolonged  constipation  is  surely  followed  by 
fu'runcles.  After  typhoid  fever,  furunculosis  and  carbuncle  are  not 
uncommon. 

The  chief  interest,  from  a  medical  point  of  view,  lies  in  the 
association  of  boil,  carbuncle,  and  glycosuria.  It  has  been  shown 
that  if  to  a  dose  of  staphylococcus  culture,  too  feeble  by  itself  to 
provoke  suppuration,  a  certain  quantity  of  grape  sugar  be  added, 
the  culture  rapidly  acquires  marked  pus-producing  properties,  and 
it  is  a  noteworthy  fact  that  boils  are  very  common  amongst  those 
engaged  in  sugar  refining.  So  firmly  has  the  connection  between 
carbuncle  and  glycosuria,  whether  diabetic  or  not,  been  insisted 
upon,  that  it  is  often  the  presence  of  the  former  which  calls  for  an 
examination  of  the  urine.  It  must,  however,  be  remarked  that 
sometimes  no  sugar  is  discovered,  or,  if  it  be,  its  presence  is  merely 
temporary,  and  it  disappears  when  the  carbuncle  has  healed.  In 
many  instances  it  is  impossible  to  doubt  the  connection  between 
the  two,  but  reliable  statistics  are  required  to  show  the  exact 
frequency  of  the  incidence  of  carbuncle  in  diabetes,  and  how  often 
sugar  is  temporarily  present  in  cases  of  carbuncle.  Some  other 
abnormal  states  of  the  urine  are  also  found  when  carbuncle  is 
present,  notably  albumen,  excess  of  phosphates,  excess  of  uric  acid, 
and  diabetes  insipidus.  Alcoholics  often  suffer  from  boil  and 
carbuncle ;  and  finally  a  hemiplegic  limb  is  not  seldom  the  site  of 
an  eruption  of  boils. 

Symptoms. — These  affections  are  characterised  by  the  follow- 
ing symptoms  : — A  boil  commences  as  a  small  itching  red  papule, 
with  a  depression  at  its  summit,  from  which  a  hair  is  seen  issuing. 
In  about  four  days  the  swelling  has  much  increased,  and  is  conical, 
and  the  seat  of  considerable  boring  pain.  Up  to  this  time  the 
swelling  is  indurated.     In  som.e  cases  no  softening  occurs,  and  the 


BOIL  AND   CARBUNCLE  6i 

boil  is  then  said  to  be  blind ;  but  more  frequently  pus  begins  to 
form  from  the  fourth  to  the  sixth  day,  and  on  the  ninth  or  tenth 
day  the  slough,  consisting  of  the  necrosed  hair  follicle  and  sebaceous 
gland,  and  some  surrounding  tissue,  is  discharged.  The  constitu- 
tional symptoms  are  not,  as  a  rule,  marked.  The  onset  of  a 
carbuncle  is  often  preceded  by  some  malaise,  and  the  general 
symptoms  are  well  defined.  In  some  instances  there  are  rigors  and 
fever,  and  the  symptoms  are  of  a  pyemic  character ;  in  others  there 
is  a  condition  of  collapse,  subnormal  temperature,  and  feeble  pulse. 
Locally,  the  site  of  the  impending  carbuncle  feels  hot  and  is  painful, 
and  soon  becomes  red ;  then  swelling  of  the  skin  occurs,  at  first 
limited,  but  slowly  increasing.  This  swelling  is  hard  and  red,  and 
gradually  becomes  dome-shaped.  In  four  to  six  days  several  vesicles 
containing  blood-stained  pus  and  serum  appear ;  these  vesicles 
break,  and  soon  openings  leading  to  the  subcutaneous  slough  are 
formed.  Meanwhile,  the  area  of  redness,  oedema,  and  pain  has 
increased,  and  the  parts  present  the  appearance  of  acute  inflamma- 
tory tension.  The  openings  may  coalesce,  and  a  large  crater,  with 
the  slough  at  the  bottom,  is  formed ;  or,  if  it  is  thought  expedient, 
the  skin  between  the  orifices  may  be  divided,  and  a  free  aperture 
made  for  the  exit  of  the  slough. 

Complications  and  prognosis. — A  boil  situated  over  a  large 
venous  trunk  becomes  dangerous  on  account  of  the  possibility  of 
phlebitis ;  and  the  so-called  malignant  facial  carbuncle,  beginning  as 
a  boil  on  the  upper  lip,  may  result  in  septic  phlebitis  of  the  labial, 
angular  and  orbital  veins,  and  of  the  superior  longitudinal  sinus. 
If  the  head,  chest,  and  abdomen  are  affected,  especially  in  diabetic 
subjects,  meningitis,  pleurisy  and  empyema,  and  peritonitis  may 
ensue.  One  case  is  recorded  where  a  carbuncle  sloughed  through 
the  whole  thickness  of  the  abdominal  wall,  exposing  the  \ascera. 
The  prognosis  of  these  affections,  therefore,  depends  upon  the  region 
affected,  the  extent  of  surface  involved,  and  the  general  condition 
of  the  patient,  especially  as  to  glycosuria,  albuminuria,  gout,  and 
alcoholism.  It  is  in  diabetic  subjects  that  the  diffuse,  very  virulent 
carbuncle  is  occasionally  seen.  Diagnosis  must  be  made  between 
boil  or  carbuncle  and  anthrax.  In  the  latter  no  pus  is  found,  and 
the  appearance  is  characteristic — a  central  black  slough,  a  ring  of 
vesicles,  and  a  hard  inflamed  base. 

Treatment  must  be  general  and  local.  Careful,  well-regulated, 
and  easily  assimilated  diet,  avoidance  of  constipation,  fresh  air  and 
exercise,  and  frequent  skin  bathing,  are  called  for.  Intestinal  anti- 
septics, such  as  /5-naphthol,  salicylate  of  bismuth,  are  of  value,  and 


62  MANUAL  OF   MEDICINE 

later  iron  and  quinine.  Yeast  has  been  vaunted  as  a  specific,  and 
nuclein  internally  may  be  of  value.  Alcohol,  in  the  form  of 
Burgundy,  or  port  wine,  or  stout,  is  useful  in  feeble  subjects ;  but 
it  should  be  prohibited  in  those  given  to  excess.  For  the  diabetic, 
opium  and  codein  are  indicated.  Locally,  the  treatment  of  boils 
must  be  on  antiseptic  lines,  and  poultices  are  to  be  avoided ;  the 
surest  means  to  ensure  crops  of  boils  is  to  use  poultices.  The  skin 
in  the  neighbourhood  of  a  boil  must  be  protected  by  collodion,  and 
the  boil  should  be  fomented  with  hot  boracic  lotion,  and,  when  ripe, 
incised.      Hot  lead  and  opium  lotion  will  often  relieve  pain. 

The  local  treatment  of  carbuncle  presents  many  difficulties.  On 
the  one  hand  we  have  to  guard  against,  especially  in  diabetics,  the 
effects  of  prolonged  pain  and  the  possibilities  of  septic  absorption, 
owing  to  the  retention  of  the  slough ;  and,  on  the  other  hand,  an 
incision  is  often  fraught  with  danger  owing  to  the  haemorrhage. 
Some  have  thought  injection  of  carbolic  acid  and  glycerine  to  be  of 
service ;  but,  with  damaged  kidneys,  it  is  not  advisable  to  do  this. 
It  seems  that  in  localised  carbuncles  frequent  hot  antiseptic  appli- 
cations will  facilitate  the  separation  of  the  slough,  and  if  much  pus 
be  present,  a  limited  incision  is  advisable.  In  large  diffuse  carbuncle 
a  small,  not  crucial,  incision  in  the  centre  may  be  called  for ;  and, 
to  avoid  the  risk  of  hemorrhage,  the  various  apertures  may  be  joined 
by  the  thermo-cautery.  Every  effort  must  be  made  to  sustain  the 
patient's  strength,  but  many  patients  with  diffuse  carbuncles  resist 
all  treatment. 

A.  H.  Tubby. 


ERYSIPELAS 


Er}'sipelas  is  an  infective  inflammation  of  the  skin  caused  by  the 
invasion  of  the  lymphatics  by  the  stj-eptococcus  erysipelafos,  accom- 
panied by  pyrexia  and  other  constitutional  disturbances.  The  in- 
flammation may  spread  from  the  skin  to  the  adjacent  mucous 
membranes,  or  it  may  start  in  the  latter  and  extend  thence  to  the 
skin. 

Pathology. — The  relationship  between  erysipelas  and  various 
forms  of  cellulitis,  septicaemia,  and  pyaemia  is  still  a  debatable 
question.  Some  hold  that  erysipelas  is  a  distinct  disease,  while 
others  consider  it  to  be  a  variety,  due  to  special  localisation,  of  a 


ERYSIPELAS  63 

disease  which  has  other  manifestations.  The  latter  view  is  adopted 
here  for  the  following  reasons,  viz.  first,  that  erysipelas  does  not 
always  "  breed  true,"  for  instance,  a  case  of  erysipelas  may  give  rise 
in  other  patients  to  cellulitis,  puerperal  fever,  or  some  other  form 
of  septicaemia ;  secondly,  that  a  case  of  typical  erysipelas  may 
gradually  develop  into  one  of  cellulitis,  or  even  of  pyaemia ;  and, 
finally,  that  the  streptococcus  erysipelatos,  which  is  the  cause  of 
erysipelas,  is  identical  with  the  streptococcus  pyogenes,  which  is  the 
cause  of  many  forms  of  septic  disease. 

A  section  through  the  affected  skin  shows  that  the  lymphatic 
vessels  and  spaces  at  the  spreading  margin  of  the  inflamed  area  are 
filled  with  micrococci  arranged  either  in  pairs  (diplococci),  or  in 
chains  (streptococci).  In  the  rest  of  the  affected  area  there  will  be 
found  a  serous  and  cellular  infiltration,  by  means  of  which  the 
micrococci  are  ultimately  destroyed.  The  inflammation  spreads 
along,  and  as  a  rule  remains  limited  to  the  skin,  because  the 
micrococci  can  travel  more  readily  along  the  lymph  spaces  than  in 
any  other  direction.  Should  they  reach  the  subcutaneous  tissue,  a 
cellulitis  is  produced ;  and  should  they  get  into  the  circulation,  a 
septicaemia  or  pyaemia  will  arise. 

Bacteriology. — From  the  affected  skin  it  is  easy  to  cultivate 
the  streptococcus  erysipelatos  causing  the  disease,  which  possesses  the 
following  characters  : — It  consists  of  cocci  arranged  in  pairs  and  in 
chains,  the  latter  being  frequently  very  long  and  convoluted.  It 
stains  with  the  ordinary  dyes,  and  is  not  decolorised  by  Gram's 
method.  It  grows  readily  in  all  the  ordinary  media,  both  in  the 
presence  and  in  the  absence  of  oxygen,  either  at  the  usual  tempera- 
ture of  the  air,  or  at  the  temperature  of  the  body.  On  the  surface 
of  solid  media,  the  colonies  are  characterised  by  being  small  and 
discrete ;  and  they  do  not  liquefy  gelatine.  In  broth  the  growth 
sometimes  occurs  as  a  uniform  turbidity,  more  frequently  as  a 
flocculent  mass  which  falls  to  the  bottom  of  the  tube,  leaving  the 
supernatant  liquid  clear. 

Fehleisen,  by  successfully  inoculating  individuals  with  pure  culti- 
vations, in  the  hope  of  curing  them  of  malignant  tumours,  furnished 
the  direct  proof  that  the  streptococcus  is  the  cause  of  erysipelas. 

So  far  as  animals  are  concerned,  the  virulence  of  the  strepto- 
coccus, and  consequently  the  effect  produced  by  inoculation,  varies. 
In  rabbits  inoculation  of  the  skin  of  the  ear  may  produce  a  condition 
similar  to  that  of  erysipelas  in  the  human  subject,  while  septicEemia 
or  suppuration  may  be  produced  by  subcutaneous  inoculation  with 
cultivations  of   appropriate  virulence.     Frequently  a  streptococcus 


64  MANUAL  OF  MEDICINE 

isolated  from  a  severe  case  in  the  human  subject  is  found  to  be 
almost  harmless  to  laboratory  animals.  The  streptococci  obtained 
from  various  cases  of  erysipelas  differ  from  one  another  not  only  in 
virulence,  but  also  to  some  extent  in  cultural  characteristics.  It 
would,  however,  appear  that  these  different  varieties  can  be  reduced 
to  a  uniform  type  by  special  means. 

By  some  the  streptococcus  pyogenes,  which  gives  rise  to  septicsemia, 
puerperal  fever,  etc.,  and  the  streptococcus  erysipelatos  are  considered 
to  be  distinct  micro-organisms.  This  view  is  based  partly  upon  the 
different  effects  produced  in  animals  by  inoculation,  and  partly 
upon  differences  in  cultivations.  The  more  we  know  about  the 
various  types  of  both  micro-organisms,  the  less  important  do  these 
differences  become ;  and  the  most  generally  accepted  view  at  the 
present  time  is,  that  the  streptococcus  erysipelatos  and  the  strepto- 
coccus pyogenes  are  identical.  Consequently,  erysipelas  cannot  be 
looked  upon  as  a  distinct  specific  disease,  although  it  may  be- 
described  as  a  clinical  entity  on  account  of  the  special  symptoms 
produced  by  the  localisation  of  the  micro  -  organisms  in  the 
skin. 

Etiology. — Erysipelas  occurs  in  almost  all  parts  of  the  world  ; 
it  attacks  persons  of  all  ages  and  of  either  sex,  and  it  appears  to 
be  more  prevalent  during  the  colder  seasons  of  the  year.  Patients 
suffering  from  chronic  Bright's  disease,  or  from  the  effects  of  chronic 
alcoholism,  and  those  living  under  bad  hygienic  conditions  are 
especially  liable  to  be  attacked.  Some  individuals  are  exceedingly 
susceptible,  and  are  attacked  again  and  again.  It  is  difficult  to 
decide  whether  such  cases  are  due  to  fresh  infection,  or  whether 
they  are  recrudescences  of  the  disease.  Whatever  may  be  the 
explanation,  the  protection  afforded  by  one  attack  is  but  slight, 
and  of  short  duration. 

The  most  common  mode  of  infection  is  by  means  of  a  wound 
in  the  skin  ;  and,  before  the  days  of  antiseptic  surgery,  erysipelas, 
when  introduced  into  a  surgical  ward,  rapidly  spread,  the  virus 
being  no  doubt  conveyed  to  the  wounds  by  the  fingers  of  those  in 
attendance.  At  the  present  time  erysipelas  is  almost  unknown 
after  surgical  operations.      It  occasionally  follows  on  vaccination. 

Patients  are  sometimes  attacked  when  there  is  no  obvious 
wound  for  the  entrance  of  the  virus.  Probably  in  such  there  was 
some  abrasion  of  the  skin,  which  had  disappeared  at  the  time  of 
observation.  In  some  cases  the  virus  enters  through  the  mucous 
membrane  of  the  fauces  or  other  parts,  and  spreads  by  direct  con- 
tinuity to  the  skin. 


ERYSIPELAS  65 

After  infection  there  is  an  incubatioa  period  of  from  one  to 
three  or  four  days,  during  which  no  symptoms  are  observed. 

Apart  from  wounds,  the  face  is  most  frequently  affected,  although 
any  part  of  the  body  may  be  attacked.  In  the  face  the  disease 
usually  arises  at  the  junction  of  the  skin  and  the  mucous  membrane, 
near  the  side  of  the  nose,  the  inner  canthus  of  the  eye,  or  the 
margins  of  the  lips.  The  affected  skin  becomes  red,  swollen,  pain- 
ful, and  tender.  The  inflammation  spreads  by  direct  continuity  to 
the  adjacent  skin,  the  edge  dividing  the  aifected  from  the  healthy 
skin  being  raised  and  well  defined.  In  parts  where  the  skin  is 
closely  adherent  to  the  subjacent  tissues,  the  spread  of  the  inflam- 
mation is  arrested.  As  the  inflammation  advances  the  redness 
disappears  from  the  part  first  affected.  Where  the  skin  is  loose,  as 
on  the  eyelids  and  the  scrotum,  the  swelling  is  intense.  Vesicles 
and  bullae  frequently  appear  over  the  affected  area.  The  inflam- 
mation lasts  for  about  a  week,  and,  as  it  subsides,  the  skin  becomes 
flaccid  and  shrivelled,  the  vesicles  dry  up,  and  desquamation  occurs. 
When  the  scalp  is  affected  there  is  considerable  oedema,  but  not 
much  redness.  The  lymphatic  glands  in  the  neighbourhood  of  the 
affected  skin  are  usually  tender  and  slightly  enlarged. 

When  a  mucous  membrane,  such  as  that  of  the  fauces,  is 
attacked,  it  becomes  swollen,  and  brawny,  and  of  a  deep  red 
colour. 

Symptonis. — The  onset  of  the  disease  is  usually  quite  sudden, 
with  rigors  and  vomiting.  The  temperature  quickly  rises  to  about 
104°  F.,  and  there  are  the  usual  accompaniments  of  fever,  headache, 
loss  of  appetite,  etc.  Albuminuria  is  generally  present,  and  nephritis 
is  by  no  means  uncommon — blood  and  casts  appearing  in  the  urine. 
Diarrhoea  is  often  a  troublesome  symptom.  Herpes  labialis  and  sore 
throat  are  of  occasional  occurrence. 

In  favourable  cases  the  temperature  falls  in  about  six  or  eight 
days,  either  by  lysis  or  more  frequently  by  crisis ;  the  inflammation 
of  the  skin  ceases  to  spread,  and  the  other  symptoms  quickly  sub- 
side. In  unfavourable  cases  the  pyrexia  may  be  high,  or  the  patient 
may  fall  into  a  typhoid  condition,  becoming  wildly  delirious,  and 
succumb  with  severe  nervous  prostration,  or  he  may  die  from  ex- 
haustion with  vomiting  and  diarrhoea. 

In  addition  to  the  acute  form  of  the  disease,  a  more  chronic 
form  occurs.  In  this  type  the  inflammation  of  the  skin  may  wander 
about  from  one  part  of  the  body  to  another ;  the  constitutional 
symptoms  are  not  as  a  rule  severe,  and  there  is  often  little  or  no 
pyrexia. 

VOT.  I  F 


66  MANUAL  OF   MEDICINE 

Relapses  occurring  shortly  after  the  first  attack  are  not  at  all 
uncommon.  With  the  relapse  the  temperature  rises,  and  fresh  in- 
flammation of  the  skin  sets  in. 

Certain  complications  may  arise  during  an  attack  of  erysipelas. 
The  inflammation  may  spread  to  the  larynx,  causing  serious  obstruc- 
tion to  the  respiration ;  or  it  may  spread  to  the  lungs,  producing 
bronchitis  and  pneumonia.  By  the  escape  of  the  streptococci  into 
adjacent  parts,  various  septic  conditions  may  arise.  The  most  fre- 
quent of  these  is  diffuse  cellulitis  ;  but  other  septic  conditions,  such 
as  meningitis,  peritonitis,  pericarditis,  pneumonia,  or  even  pyaemia, 
are  by  no  means  unknown. 

An  attack  of  erysipelas  may  give  rise  to  a  blocking  of  the  lymph- 
atics, and  thus  cause  permanent  oedema.  This  is  especially  frequent 
in  the  subcutaneous  tissues  below  the  eyes,  where  large  bladder-like 
swellings  may  occur.  Erysipelas  of  the  scalp  often  causes  loss  of 
hair.  Sloughing  of  the  cornea  and  suppurative  otitis  have  been  met 
with  as  later  results. 

A  beneficial  influence  is  sometimes  exerted  by  an  attack  of  erysi- 
pelas upon  chronic  skin  diseases  and  certain  varieties  of  sarcoma ;  in 
fact  a  complete  disappearance  of  the  latter  may  occur,  so  that  inocu- 
lation of  patients  with  erysipelas  has  been  performed  with  a  therapeutic 
object.  It  was  found,  however,  that  the  erysipelas  thus  set  up  was 
too  severe  to  justify  a  continuation  of  the  treatment.  The  toxines 
produced  by  the  streptococcus  erysipelatos  are  now  employed  with 
the  same  object.  The  toxines  are  prepared  by  cultivating  the 
streptococcus  and  the  bacillus  prodigiosus  together  in  broth.  The 
bacteria  are  separated  by  filtration  through  porcelain,  and  the  filtrate 
used  for  injection  (Coley's  fluid).  The  effect  of  the  injections  is  to 
cause  pyrexia  and  general  malaise,  and  in  a  number  of  instances  the 
tumours  have  disappeared. 

Diagnosis.— Erysipelas  is  usually  quite  easy  to  diagnose,  the 
red  swollen  skin,  with  a  well-defined  raised  edge,  accompanied  by 
pyrexia  and  constitutional  symptoms,  being  quite  unmistakable. 
The  difficult  cases  are  those  in  which  the  disease  assumes  a  chronic 
type,  with  slight  or  no  pyrexia.  Commencing  herpes  on  the  face  may 
resemble  erysipelas,  but  the  rapid  appearance  of  vesicles  and  their 
distribution  quickly  clears  up  the  diagnosis.  Various  forms  of  ery- 
thema can  be  distinguished  by  the  absence  of  severe  constitutional 
disturbances,  and  by  some  distinctive  peculiarity  in  the  character  and 
distribution  of  the  patches.  An  erythema  occurring  during  the 
course  of  Bright's  disease  may  give  rise  to  difficulties  in  diagnosis. 
Acute  eczema  is  easily  distinguishable  by  the  nature  of  the  lesions. 


ERYSIPELAS  67 

In  cases  of  doubt,  a  cultivation  taken  from  the  affected  area  of  skin 
will  settle  the  diagnosis. 

It  is  not  proposed  to  discuss  the  differential  diagnosis  between 
erysipelas  and  diffuse  cellulitis,  as  the  diseases  are  considered  to  be 
etiologically  identical. 

Prognosis. — In  the  aged,  and  in  patients  suffering  from  Bright's 
disease,  chronic  alcoholism,  or  some  other  debilitating  disorder,  the 
prognosis  is  unfavourable.  It  is  less  favourable  in  patients  suffering 
from  wounds  than  in  those  in  whom  the  disease  appears  to  be  "  idio- 
pathic." Erysipelas  starting  at  the  umbilical  cord  in  infants  is  of 
bad  prognosis.  Unfavourable  symptoms  are  severe  pyrexia,  delirium, 
the  typhoid  state,  severe  vomiting,  and  diarrhoea. 

Treatment. — The  treatment  of  erysipelas  falls  under  three  head- 
ings— general,  local,  and  specific.  The  general  treatment  is  such  as 
is  applicable  to  all  fevers.  The  patient  should  be  put  upon  a  light 
nutritious  diet,  and  stimulants  should  be  administered  as  may  be 
necessary.  Drugs  do  not  cut  the  disease  short,  but  iron  is  stated  to 
be  beneficial.  The  best  local  treatment  is  to  apply  a  powder,  con- 
sisting of  zinc,  starch,  and  boracic  acid,  over  the  inflamed  skin,  and 
to  exclude  the  air  by  lint  and  a  bandage,  or,  in  the  case  of  facial 
erysipelas,  by  a  mask.  Lead  and  opium  lotion  is  useful  for  relieving 
pain.  Painting  a  band  with  solid  nitrate  of  silver  at  the  edge  of 
the  affected  area  sometimes  prevents  the  spread  of  the  inflamma- 
tion.    Should  diffuse  cellulitis  arise,  incisions  may  be  required. 

The  specific  treatment  consists  in  the  injection  of  antistrepto- 
coccic serum.  This  serum  is  that  of  the  horse,  immunised  to  the 
streptococcus  by  repeated  inoculations.  It  should  be  injected  into 
the  subcutaneous  tissue  once  or  twice  a  day,  in  doses  of  20  c.c, 
strict  antiseptic  precautions  being  taken.  In  some  forms  of  strepto- 
coccal infection  the  serum  is  certainly  beneficial,  but  at  present  the 
results  with  erysipelas  are  somewhat  doubtful.  It  may  reasonably 
be  expected  that  a  more  efficacious  serum  will  be  ultimately  ob- 
tained. 

J.  W.  Washbourn. 


6g  MANUAL  OF  MEDICINE 


SAPR^MIA,   SEPTICEMIA,   PYEMIA 

Until  a  comparatively  recent  period  any  description  of  pyaemia 
and  the  allied  diseases  would  have  been  almost  out  of  place  in  a 
text-book  of  medicine,  but  in  the  present  day,  when  antiseptic 
methods  have  practically  revolutionised  surgery,  it  has  come  to  be 
recognised  that  many  of  the  septic  conditions— the  so-called  blood 
poisonings — have  to  be  reckoned  with  chiefly  as  the  result  of  absorp- 
■  tion  from  internal  cavities  rather  than  as  arising  from  absorption 
from  external  wounds  produced  by  accident  or  by  the  surgeon ;  and 
although  in  certain  cases  it  may  be  necessary  for  the  surgeon  to 
interfere,  most  of  the  cases  of  so-called  blood  poisoning,  now  recog- 
nised, come  under  the  observation  of  the  physician  or  the  obstetric 
physician  rather  than  into  the  province  of  the  pure  surgeon. 

During  the  early  transition  period  of  bacteriology,  and  as  the 
result  of  the  work  of  Panum  with  his  "sepsines,"  and  Selmi  with 
his  "ptomaines,"  there  crept  into  medical  momenclature  two  terms 
to  indicate  what  originally  was  spoken  of  as  "  blood  poisoning  " — 
pyaemia  and  septicsemia,  the  former  including  acute  pyaemia,  in 
which  metastatic,  usually  miliary,  abscesses  are  formed  in  different 
organs  and  parts  of  the  body,  and  a  chronic  form  in  which  abscesses 
appear  fewer  in  number,  of  larger  size  and  slower  growth,  and 
often  localised  around  the  joints.  Under  septicaemia  were  in- 
cluded all  other  cases  of  septic  poisoning  not  followed  by  the 
formation  of  purulent  foci.  This  was  a  most  useful  classification 
from  the  clinical  point  of  view,  and  especially  when  our  knowledge 
of  the  action  of  microbes  and  their  products  was  both  more  re- 
stricted and  less  accurate  than  it  now  is.  With  our  present  know- 
ledge of  the  relations  of  micro-organisms  and  their  products  to 
disease  processes  it  is  necessary  to  divide  into  three  groups  the 
constitutional  and  general  symptoms  produced  by  the  entrance  of 
the  products  of  these  microbes,  alone  or  along  with  the  organisms 
that  produce  them,  into  the  living  body.  First  are  those  states 
determined  by  the  absorption  of  the  poisonous  products  of  bacteria 
from  a  localised  manufactory,  the  organisms  remaining  locahsed  but 
the  poisons  being  absorbed  and  carried  to  various  parts  of  the 
body.  This  condition,  known  as  saprtemia,  or  true  toxaemia, 
depends  entirely  on  the  iiivasioti  of  the  system  by  the  poisonous 
products    of  bacteria.       The    organisms    themselves   remain  in  the 


SAPR^MIA,  SEPTICEMIA,  PYEMIA  69 

wound,  or  it  may  be  in  the  hollow  organ  in  the  altered  secretions 
of  which  they  are  flourishing,  but  they  produce  active  toxic  agents 
which  are  rapidly  absorbed  into  the  fluids  and  tissues.  Kill  the 
organisms  in  the  wound,  or  wash  out  the  cavities  in  which  they 
are  flourishing,  and  the  sapraemic  or  toxic  symptoms  are  immedi- 
ately relieved  or  entirely  removed.  The  poison  does  not  multiply 
in  the  blood ;  it  simply  acts  as  an  absorbed  chemical  substance, 
and  unless  the  initial  dose  be  large  or  of  exceedingly  lethal 
character  the  patient  may  recover  as  soon  as  the  local  manufactory 
is  closed  or  done  away  with.  Examples  of  this  sapraemic  condition 
are  diphtheria  and  tetanus,  although  multiplication  of  the  poison- 
producing  organisms  may  sometimes  take  place  in  the  tissues.  The 
real  sapraemic  condition  is  that  in  which  there  is  absorption  of  the 
formed  poison  from  without,  as  in  very  acute  cases  of  tetanus, 
where  the  poison  is  produced  entirely  outside  the  body,  or  in 
cases  of  absorption  from  the  intestines  of  the  poisonous  substances 
produced  by  rapidly  multiplying  organisms,  which  may  be  likened 
to  the  vegetable  alkaloids  as  regards  the  toxic  effects  they  set  up. 
Exactly  the  same  process  may  be  observed  in  the  post-partum 
toxaemias  or  saprasmias,  resulting  from  the  putrefactive  changes 
that  occur  in  remnants  of  the  placenta,  or  in  clots  left  in  the  uterus  ; 
or  again  as  the  result  of  absorption  from  a  localised  abscess,  or  any 
mass  of  dead  and  decomposing  tissue  within  the  body.  When 
operations  were  performed  without  antiseptic  precautions,  toxic 
absorption  was  one  of  the  causes  of  the  fever  and  collapse  that  so 
frequently  and  shortly  supervened. 

The  organisms  which  produce  many  of  these  poisons  are 
entirely  saprophytic  and  can  never  invade  the  body  themselves  ; 
their  products,  gaseous  or  liquid,  however,  appear,  as  already  men- 
tioned, to  have  the  power  of  poisoning  tissue  cells  and  thus  of 
preparing  the  way  for  the  advance  of  the  true  pathogenetic 
organisms  into  the  tissues.  Panum,  Selmi,  Burdon  Saunderson 
and  Koch  ascribe  certain  very  definite  symptoms  and  conditions 
to  what  are  called  sepsines  or  ptomaines  (alkaloids  which  are  pro- 
duced by  the  action  of  putrifying  organisms  on  animal  tissues  or 
fluids).  Putrid  solutions  containing  these  substances  still  remain 
poisonous  after  they  have  been  boiled,  showing  that  the  action  is 
not  due  to  the  presence  of  micro-organisms,  or  even  of  enzymes, 
but  to  other  more  stable  chemical  substances  produced  by  them. 
It  is  probable  that  in  addition  to  those  that  are  unaltered  by  heat, 
there  are  others  similar  to  the  diphtheria  and  tetanus  toxins,  which 
contain,  in   addition  to  ptomaines,  enzymes  or  ferments,  some  of 


70  MANUAL   OF   MEDICINE 

which  have  a  very  poisonous  action,  although  it  takes  some  time 
for  this  action  to  become  fully  developed.  It  is  interesting  to 
notice  that  these  ptomaines  injected  into  animals  give  rise  to  fever, 
gastric  and  intestinal  disturbance,  muscular  irregularity,  weakness, 
and  increased,  or  sometimes  diminished  rate  in  respiration  and  pulse, 
not  always  but  frequently  similar  to  those  met  with  in  the  human 
subject  in  cases  of  sapraemia,  the  differences  being  apparently  due 
to  the  difference  in  dose.  Collapse  in  the  ordinary  sense  of  the 
term  may  be  said  to  be  the  most  marked  feature  following  the  in- 
jection. Certain  of  these  poisons  apparently  exert  a  direct  action 
on  the  endothelium  of  the  blood  vessels  and  even  upon  the  cor- 
puscles, these  cells  undergoing  marked  degenerative  changes. 

Symptoms. — As  in  cases  of  diphtheria,  the  poison  formed  by 
the  organisms  at  the  seat  of  the  wound  exerts  a  depressing  influence 
not  only  on  the  tissue  near  the  wound,  but  also  in  distant  parts  of 
the  body,  with  the  result  that  these  tissues  are  rendered  much  less 
capable  of  resisting  the  invasion  of  other  organisms  that  have  found 
their  way  to  the  wound.  Similarly  absorption  of  toxic  substances  by 
the  walls  of  the  larger  cavities  may  produce  marked  depression  and 
materially  diminish  the  general  powers  of  resistance,  sometimes  even 
causing  collapse  or  recurrent  shock,  where  the  absorption  goes  on  very 
rapidly,  but  intermittently.  It  has  been  noted  by  the  surgeon  that 
where  absorption  has  taken  place  from  a  wound  that  has  not  been 
kept  clean,  the  first  symptoms  make  their  appearance  soon  after 
any  change  is  observed  in  the  wound  itself;  the  temperature  rises 
three  or  four  degrees ;  rigors  often  occur  (though  these  may  be 
absent) ;  afterwards  headache,  vomiting  and  great  thirst  supervene ; 
the  skin,  at  first  pallid,  becomes  flushed,  hot  and  dry,  and  the  pulse 
and  respirations  increase  in  rapidity.  Beyond  these  and  some 
symptoms  of  intestinal  irritation,  nothing  may  be  observed,  and  the 
patient  may  quickly  recover.  In  more  marked  cases  the  patient 
becomes  rapidly  worse.  Watson  Cheyne,  in  describing  this  con- 
dition, says  :  "  There  is  excessive  muscular  weakness,  as  evidenced 
by  tremors  ;  the  tongue  is  now  dry,  brown  and  very  tremulous  ;  the 
mouth  and  lips  are  covered  with  sordes  ;  diarrhoea  may  come  on 
and  motions  and  urine  be  passed  unconsciously.  The  skin  may 
be  slightly  jaundiced  and  petechiae  may  appear.  The  temperature 
may  fall  even  to  subnormal ;  coma  comes  on  and  gradually  deepens 
into  death.  Death  usually  occurs  about  the  second  or  third  day  of 
the  disease,  but  in  other  cases  may  be  postponed  for  another  week, 
the  patient  passing  into  a  typical  '  typhoid  state '  and  dying  of 
exhaustion." 


SAPR^MIA,  SEPTICEMIA,  PYEMIA  71 

The  diagnosis  is  comparatively  easy  from  the  fact  that  the 
symptoms  are  so  marked  and  bear  such  a  definite  relation  to 
changes  in  wounds,  accumulation  and  decomposition  of  secretions, 
etc.,  in  cavities  and  the  like.  It  is  maintained  that  the  shock  which 
makes  its  appearance  where  large  surfaces  are  exposed  to  the  action 
of  septic  material,  especially  when  it  occurs  on  the  second  or  third  day 
of  such  exposure,  is  due  almost  entirely  to  this  sapraemic  condition. 

If  it  is  possible  to  remove  the  local  source  of  the  poison,  or  to 
remove  the  substances  in  which  the  organisms  are  growing,  the 
prognosis  should  always  be  favourable,  except  in  patients  of  low 
vitality.  The  saprsemic  condition,  however,  by  increasing  the 
vulnerability  of  the  tissues,  renders  the  patient  peculiarly  hable  to 
be  attacked  by  septicaemia. 

The  treatment  in  such  cases  is  evident.  Remove,  as  carefully 
as  possible,  by  curetting,  free  drainage,  and  by  constant  irrigation 
with  warm  sterile  water  or  weak  antiseptic  lotion,  the  substances  in 
which  the  organisms  are  growing.  General  medical  and  surgical 
treatment  should  also  be  attended  to,  and  the  strength  of  the 
patient  kept  up  by  means  of  nourishing,  but  non-stimulating  diet. 

Septicemia  differs  in  certain  essential  details  from  saprsemia, 
although  it  must  really  be  looked  upon  as  an  extension  of  that 
condition.  The  characteristic  feature  of  septicaemia  is  that  it  is 
brought  about  by  the  entrance  into  the  vascular  system  of  active 
micro-organisms  a/otig  with  their  poisons ;  consequently  the  con- 
dition may  be  very  prolonged,  the  prognosis  as  a  rule  being  much 
more  grave.  The  gravity  of  the  condition  consists  in  the  fact  that 
the  active  micro-organisms  are  able  to  exist  and  multiply  within  the 
body  where  it  is  impossible  to  get  at  them  for  the  purpose  of 
diminishing  their  vitality,  and  of  there  continuing  to  carry  on  the 
manufacture  of  the  poisonous  substances  which  are  the  active  agents 
in  bringing  about  devitalisation  of  the  tissues. 

In  a  case  of  saprsemia,  as  soon  as  the  local  manufactory  of  the 
poison  is  removed,  the  patient,  if  the  process  has  not  gone  too  far, 
commences  to  recover,  since  there  is  no  further  production  of 
poison.  In  the  case  of  septicaemia,  on  the  other  hand,  the  original 
local  manufactory  may  be  removed,  but  the  formation  of  the  poison 
is  still  continued  by  the  organisms  that  have  found  their  way  into 
the  body.  The  onset  of  the  disease  may  be  much  slower,  as  the  in- 
vading organisms  may  take  some  time  to  make  good  their  position 
in  the  tissues  and  fluids  of  the  body,  and  until  they  are  able  to  do 
this  they  are  incapable  of  manufacturing  any  very  large  quantities  of 


72  MANUAL  OF  MEDICINE 

poison.  It  is  quite  possible  that  the  distinction  between  saprsemia 
and  septicaemia  might  be  broken  down,  were  it  not  that  in  cases  of 
septicaemia  pyogenic  cocci,  few  in  number,  no  doubt,  may  usually 
be  found  in  the  blood ;  though,  did  not  the  production  of  the 
poison  go  on  after  the  local  manufactory  had  been  removed,  one 
might  imagine  that  the  presence  of  such  organisms  was  merely 
accidental.  On  examining  the  organs  of  such  a  case  of  septicaemia, 
however,  long  before  the  abscesses  have  been  found,  there  may 
usually  be  demonstrated  in  the  kidneys,  sometimes  in  the  liver  and 
lungs,  and  more  frequently  in  the  tissues  of  the  heart,  a  number  of 
micro-organisms  usually  staphylococci  or  streptococci,  though  here 
and  there  bacilli  may  be  found.  In  one  case  of  haemorrhagic  septi- 
caemia that  I  examined,  both  bacilli  and  cocci,  singly  and  in  masses, 
were  present  in  large  numbers  in  the  capillary  vessels.  Perhaps 
the  most  common  of  the  septicaemias  are  those  of  purulent  origin; 
those  following  certain  specific  infective  febrile  diseases,  especially 
of  the  exanthematous  type ;  those  following  wounds,  particularly 
post-mortem  and  dissecting  wounds,  the  septic  organisms  appearing 
to  assume  a  special  virulence  in  the  tissues  and  fluids  of  dead 
bodies,  and  of  patients  that  have  suffered  from  purulent  inflam- 
mation of  the  serous  surfaces  of  the  joints,  peritoneum  or  pleura. 
In  certain  cases,  lowered  vitality  of  the  tissues  appears  to  be  almost 
an  essential  predisposing  cause  ;  devitalisation  of  the  tissues,  whether 
by  injury,  malnutrition,  or  action  of  poisons,  seems  to  play  a  very 
important  part  in  the  production  of  these  septicaemias ;  whilst,  as 
in  the  case  of  sapraemia,  anything  that  interferes  with  the  free  dis- 
charge from  the  surface  of  the  wound,  or  from  the  cavities  of  the 
body,  is  also  a  powerful  predisposing  agent. 

Septicaemia  as  a  special  condition  is  now  seldom  observed  ;  but 
even  within  the  last  twenty-five  years  deaths  from  septicaemia  follow- 
ing operations  and  in  the  maternity  hospitals  were  by  no  means  un- 
frequent.  Badly  ventilated  and  dirty  hospitals,  infected  instruments, 
imperfect  antiseptics  and  the  like,  now  comparatively  rare,  then  played 
an  exceedingly  important  part  in  the  production  of  this  condition. 

The  diagnosis  of  septicaemia  is,  as  a  rule,  either  very  easy  or 
very  difficult :  easy  where  there  is  an  evident  wound,  sometimes  a 
very  small  one,  merely  a  pin-prick,  and  when  the  process  comes  on, 
perhaps,  at  first  slowly,  but  afterwards  rapidly.  It  may  commence 
within  twenty-four  hours  of  inoculation,  with  rigors,  sometimes  re- 
peated, followed  by  a  rapid  rise  of  temperature  of  from  4°  to  6°  F.  ; 
the  pulse  "becomes  rapid,  feeble,  and  irregular,  and  the  heart  weak ; 
vomiting,  headache,  delirium,  at  first  acute,  and  latterly  of  the  low 


SAPR^MIA,  SEPTICEMIA,  PY.EMIA  73 

muttering  typhoid  type,  almost  always  occur ;  and  the  lungs  become 
congested,  or  the  patient  suffers  from  bronchitis — in  fact  the  patient, 
as  in  sapraemia,  frequently  passes  into  the  "  typhoid  condition." 
The  skin  has  a  peculiar  pallid,  yellowish  tinge,  especially  about  the 
angles  of  the  nostril  and  mouth,  and  there  may  be  small  subcutane- 
ous hcemorrliages.  The  breath  has  a  peculiarly  sweet,  new-mown-hay 
smell.  In  milder  cases  the  symptoms  are  simply  less  marked,  the 
skin  does  not  become  so  markedly  yellow,  and  the  small  haemor- 
rhages so  characteristic  of  the  very  acute  cases  are  not  seen.  Rigors 
also  are  less  characteristic  of  the  milder  than  of  the  more  acute  forms. 
Where  septicsemia  is  the  result  of  a  small  or  punctured  wound  the 
organisms  sometimes  seem  to  spread,  especially  along  the  lymphatic 
channels,  v/hich  may  then  become  acutely  inflamed,  appearing  as 
distinct  red  hues  on  the  surface  of  the  skin.  There  is  often  acute 
pain  ;  and  in  consequence  of  the  changes  that  occur  in  the  lymphatic 
vessels  the  tissues  of  the  limb  become  oedematous,  the  glands  become 
tender,  and  afterwards  may  suppurate.  This  is  not  really  a  septi- 
Ccemia,  but  an  acute  lymphangitis.  If  the  process  is  not  arrested  at 
the  glands  nearest  to  the  wound,  the  patient  usually  succumbs  very 
rapidly  to  an  acute  septicaemia  or  pyaemia. 

The  prognosis  in  acute  cases  of  septicaemia  is  very  unfavourable. 
Those  in  robust  health  have  a  better  chance  of  recovery  than  those 
weakened  by  disease,  bad  hygienic  conditions,  or  impaired  nutrition. 

Treatment  is  directed  to  the  amelioration  of  the  symptoms  ;  the 
removal  of  the  local  cause  by  excision,  thorough  drainage  and  irriga- 
tion, and,  if  necessary,  cauterisation.  The  strength  of  the  patient 
should,  as  far  as  possible,  be  maintained  by  the  exhibition  of  suitable 
food,  by  controlling  the  temperature,  and  by  relieving  the  pain. 

In  all  cases  of  either  septicaemia  or  pyaemia  where  streptococci 
can  be  demonstrated  in  the  blood  or  in  the  tissues,  or  even  when 
their  presence  is  suspected,  full  doses  of  antistreptococcic  serum 
should  be  injected  as  early  as  possible,  and  should  be  repeated  as 
often  as  may  be  found  necessary. 

Pyaemia. — It  has  been  stated  that  in  septicaemia  micro-organisms 
may  be  found  in  the  blood ;  but  no  metastatic  abscesses  were  de- 
scribed, the  patient  usually  succumbing  to  the  action  of  the  acute 
specific  poison  before  there  has  been  time  for  the  formation  of 
abscesses. 

In  pysemia,  as  early  indicated  by  Lister,  and  later  by  Ribbert,  it 
is  probable  that  septic  inflammation  of  a  vein  or  veins  is  usually  set 
up  in  the  immediate  neighbourhood  of  a  septic  wound.     As  the  result 


74  MANUAL  OF  MEDICINE 

of  the  changes  that  take  place  in  the  endothehum  of  the  vein  so 
affected,  there  is  usually  a  local  deposition  of  fibrin  in  which  strepto- 
cocci or  staphylococci  may  develop,  sometimes  in  large  numbers. 
A  septic  thrombus  is  thus  formed  which  naturally  undergoes  soften- 
ing, the  clot  going  through  what  may  almost  be  spoken  of  as  suppu- 
rative changes  ;  and  as  this  continues,  and  the  clot  softens  and  breaks 
down,  fragments  set  free  are  carried  as  emboli  to  the  capillaries, 
where,  becoming  impacted,  they  form  foci  around  which  abscesses — 
sometimes  very  small,  at  other  times  running  together  into  larger 
suppurating  masses — are  formed. 

It  was  pointed  out  by  Koch  that  micro-organisms  finding  their 
way  into  the  blood  may  multiply  or  be  massed  together,  entangling 
blood  corpuscles,  into  small  floating  agglomerations  which,  carried 
into  the  capillary  system,  become  impacted,  and  so  form  the  centres 
of  abscesses. 

Here  it  should  be  borne  in  mind  that  the  healthy  tissues  of  the 
body  have  a  great  power  of  destroying  micro-organisms,  and  to  this 
must  be  attributed  the  fact  that  although  septic  organisms  must  be 
distributed  throughout  the  body,  and  to  all  the  organs,  abscesses  may 
be  met  with  only  in  a  single  organ,  or  in  the  synovial  membrane  of 
a  single  joint.  It  is  supposed,  indeed,  that  by  some  means  or  other 
the  organ  affected  has  been  deprived  of  its  resisting  power,  or  the 
tissues  of  the  joint  have  had  their  vitality  lowered  by  an  old  inflam- 
matory condition,  a  bruise,  or  a  wound.  In  certain  cases  of  acute 
pyaemia  following  surgical  operations,  the  kidneys  only  may  be 
affected.  For  this  two  reasons  have  been  assigned :  the  first  is  that 
in  this  organ  there  is  a  double  set  of  capillaries,  and  that  consequently 
the  small  masses  of  organisms  which  might  pass  through  a  single  set 
of  capillaries  are  entangled  by  a  second  set,  because  of  the  extreme 
slowness  of  the  circulation  at  this  point.  A  second  explanation  is 
one  which  receives  some  countenance  from  the  experiments  carried 
out  by  Sherrington  and  others,  that  the  micro-organisms  making 
their  way  from  the  capillary  system  into  the  tubules  are  allowed  to 
rest,  especially  at  points  where  the  tissues  have  their  vitality  in  any 
way  impaired  ;  here  they  increase  in  number,  and  become  the  centres 
of  abscess  formation. 

That  pyccmic  abscesses  are  in  many  cases,  though  not  invariably, 
the  result  of  emboli,  must  now  be  generally  accepted.  They  may 
follow  on  alterations  in  the  endocardium,  and  the  settling  of  micro- 
organisms upon  the  altered  tissues,  with  a  subsequent  increase 
in  size  and  softening  of  the  vegetation.  The  secondary  abscesses, 
the  result  of  the  impaction  of  emboli,  are  usually  first  manifest  in  the 


SAPR.-EMIA,   SEPTICEMIA,   PY.EMIA  75 

lungs,  especially  when  the  pysemic  process  commences  in  connection 
with  the  bones  or  periosteum,  where  apparently  the  emboli  are  larger, 
and  are,  therefore,  caught  more  certainly  in  the  comparatively  wide 
pulmonary  capillaries.  Multiple  abscesses  in  such  cases  are  formed  ; 
but  it  is  only  when  they  are  of  some  size,  and  are  near  the  surface, 
that  any  definite  signs  and  symptoms  are  obtained,  being  mainly 
those  of  pleuro-pneumonia  and  empyema. 

Once  a  mass  of  pyogenetic  organisms,  detached  from  such  a 
thrombus  in  a  vessel  or  vegetation,  becomes  impacted,  it  may  be  the 
centre  of  a  pyemic  abscess  from  the  fact  that  these  organisms  form 
substances  which  exert  a  marked  devitalising  effect  on  the  wandering 
cells  which  attempt  to  get  into  the  neighbourhood  of  the  organisms, 
and  on  the  fixed  cells  that  are  there  already.  The  wall  of  the  vessel 
in  which  the  micro-organisms  are  fixed  is  similarly  devitalised,  and 
the  pyogenetic  cocci  gradually  make  their  way  through  the  dead 
tissue  or  vessel  wall  into  the  surrounding  area,  their  advance  being 
Hmited  only  by  the  presence  of  an  enormous  number  of  leucocytes 
which  are  found  wandering  towards  them.  The  leucocytes  near  the 
organisms  are  involved  in  the  general  death  of  the  tissues ;  but 
others  come  up  to  take  their  place,  and  gradually,  if  these  and  the 
tissues  are  moderately  healthy,  they  form  a  zone  of  active  resistant 
cells.  In  addition  to  the  poison  that  causes  the  death  of  the 
leucocytes,  the  pysemic  organisms  secrete  a  substance  which  has  the 
power  of  peptonising  or  digesting  the  dead  tissues  and  cells,  both 
those  originally  constituting  the  part  and  the  leucocytes  that  have 
come  to  reinforce  them. 

Pyaemia  is  now  comparatively  rarely  met  with,  except  as  following 
diftuse  suppurating  cellulitis,  ulcerative  conditions  of  the  internal 
organs,  or  suppurations  near  large  veins,  in  bones,  and  in  cavities 
which  may  become  closed,  or  that  have  bony  walls,  such  as  the 
middle  ear,  the  antrum  or  frontal  sinuses,  or  in  thrombosis  of  the 
cerebral  sinuses. 

Sjnnptoms. — From  the  nature  of  the  process,  pysemia  must  be 
expected  at  a  somewhat  later  period  than  either  saprsemia  or  septi- 
csemia,  but  it  usually  occurs,  as  pointed  out  by  Watson  Cheyne, 
"within  the  first  week  of  injur}'  or  operation." 

The  first  symptom,  of  course,  in  surgical  work,  is  the  unhealthy 
appearance  of  the  wound.  The  veins  leading  from  the  wound  may 
become  indurated  and  painful,  and  the  area  of  connective  tissue 
drained  by  the  wound  inflamed  and  cedematous.  Before  this,  the 
patient  is  uneasy  and  feverish,  loses  his  appetite,  and  usually  suffers 
from  great  thirst.     The  bowels  may  be  constipated,  or  there  may 


76  MANUAL  OF   MEDICINE 

be  persistent  diarrhoea.  After  a  slight  rise  in  temperature,  rigors 
occur,  during  which  the  temperature  may  rise  5°  or  6"  F.,  or  even 
more.  The  rigors  are  followed  by  very  profuse  sweating,  during 
which  the  temperature  may  fall  to  100°  or  101°,  or  may  become 
subnormal.  Vomiting  is  a  fairly  common  symptom.  There  is  furring 
of  the  tongue,  which  later  becomes  brown,  dry,  and  hard — the  so- 
called  "  parrot's  tongue  "  ;  the  teeth  and  the  lips  are  covered  with 
sordes.  The  action  of  the  heart  becomes  weakened,  the  pulse  very 
rapid,  soft,  feeble,  and  irregular.  The  respirations  are  increased  in 
number.  The  muscles  become  soft  and  flabby.  The  patient  becomes 
intermittently  delirious,  and  ultimately  falls  into  the  "  typhoid  state." 
There  may,  however,  be  a  more  acute  delirious  condition,  the  patient 
usually  complaining  greatly  of  headache.  Rashes  resembling  the 
scarlet-fever  rash  are  described  as  occurring,  first  in  the  large  folds 
of  skin  spreading  up  and  down  the  limbs.  Sometimes  there  is  a 
"pustular  rash,"  and  "in  the  later  stages  of  the  disease  petechise  are 
not  uncommon,  or  extensive  cutaneous  haemorrhages  may  occur." 
The  yellowness  of  the  skin  and  the  sweet-hay  smell  of  the  breath, 
described  in  septicaemia,  are  also  present  in  this  condition.  The 
patients  usually  succumb  to  the  disease  at  about  the  eighth  to  the 
twelfth  day,  though  they  may  live  longer.  They  die  of  exhaustion, 
and  are  usually  comatose  before  death,  though  some  such  condition 
as  meningitis,  cerebral  abscess,  congestion  of  the  lungs,  ulcerative' 
endocarditis,  may  be  the  immediate  cause  of  the  fatal  issue. 

The  spleen  usually  becomes  enlarged  and  tender.  Abscesses  may 
be  formed,  which,  bursting  into  the  peritoneal  cavity,  set  up  peri- 
tonitis. There  may  be  multiple  abscesses  in  the  kidneys,  or  in  the 
brain,  often  accompanied  by  purulent  meningitis.  Sudden  blind- 
ness, due  to  plugging  of  the  central  artery,  or  optic  neuritis  with 
retinal  haemorrhages,  may  also  occur.  Suppuration  of  the  serous 
membranes  of  the  joints  and  peritoneal  and  pericardial  cavities  is 
frequently  met  with.  Suppurations  of  the  cellular  tissue  are  fairly 
common. 

The  Diagnosis  of  pyaemia,  apart  from  the  condition  of  a  surgical 
wound,  an  injury,  or  middle-ear  suppuration,  is  often  very  difficult, 
and  unless  some  local  mischief  can  be  traced,  pyaemia  may  readily 
be  mistaken  for  typhoid  fever.  Apart  from  the  source  of  infection, 
the  temperature  charts  are,  however,  usually  quite  different  and 
characteristic — in  the  case  of  pyemia  the  curve  being  irregular, 
whilst  in  the  case  of  typhoid  there  is  the  typical  evening  rise  and 
the  gradual  upward,  but  remittent,  tendency  of  the  curve  during  at 
least   the   first   week.       In   typhoid   fever  the   rigors  and  sweating 


INFECTIVE   ENDOCARDITIS  77 

do  not  recur,  and  as  a  rule  no  suppurative  changes  supervene. 
The  rose  rash  of  the  latter  is  perfectly  distinct  from  the  petechial 
haemorrhages  so  characteristic  of  pysemia. 

The  prognosis  is  invariably  grave,  especially  where  the  disease 
takes  the  form  of  ulcerative  endocarditis  or  of  pyEemia  of  the  portal 
system,  where  the  secondary  deposits  occur  in  the  liver. 

Where  no  vital  organs  are  affected,  the  patient  may  recover ; 
but  there  is  often  considerable  loss  of  tissue  or  adhesion  of  joint 
surfaces,  so  that  deformed  and  stiff  joints  may  remain. 

The  treatment  of  such  a  fatal  disease  is  naturally  of  little  effect ; 
but  when  such  cases  do  get  well,  it  is  because  the  strength  of  the 
patient  is  kept  up,  and  because  there  is  a  free  excision  of  the  suppu- 
rating surfaces,  a  destruction  of  the  micro-organisms  in  discharges  by 
a  free  use  of  antiseptics,  and  in  extreme  cases  by  the  removal,  by 
dissection,  of  the  thrombosed  vein  or  veins,  with  their  contained 
abscess-producing  organisms,  and  thoroughly  draining  and  washing 
out  the  resulting  wounds  with  warm,  weak  antiseptic  solutions. 

G.  Sims  Woodhead. 


INFECTIVE  ENDOCARDITIS 

The  term  malignant,  ulcerative,  or  infective  endocarditis,  is 
applied  to  a  form  of*  septicaemia  or  pyaemia  in  which  the  virus 
especially  attacks  the  endocardium.  The  inflammatory  lesions  in 
the  endocardium  differ  essentially  from  those  of  a  simple  or  benign 
endocarditis,  such  as  is  associated  with  acute  rheumatism,  in  con- 
taining bacteria  of  various  kinds.  It  is  to  the  presence  of  these 
bacteria  that  the  septic  character  of  the  symptoms  is  due. 

Pathology  and  post-morterQ  appearances. — The  bacteria 
most  commonly  present  are  the  streptococcus  pyogenes,  the  pneu- 
mococcus,  and  the  staphylococcus  pyogenes  aureus.  Much  less 
frequently  other  bacteria,  such  as  the  gonococcus,  the  typhoid 
bacillus,  and  the  tubercle  bacillus  are  present. 

These  different  bacteria  may  enter  the  body  through  the  various 
portals  by  which  the  body  is  usually  invaded  by  bacteria,  through 
the  respiratory  or  the  digestive  tract,  the  ureihra  or  vagina,  or 
through  the  skin.  As  a  rule,  there  is  some  primary  lesion  at  the 
seat  of  inoculation,    and  thus  infective   endocarditis  is    commonly 


78  MANUAL   OF   MEDICINE 

preceded  by  and  occurs  as  a  complication  or  sequela  of  such 
diseases  as  pneumonia,  puerperal  fever,  septic  wounds,  etc.  Less 
frequently  there  is  no  obvious  primary  lesion,  and  therefore  no 
evidence  of  the  mode  by  which  the  virus  has  gained  entrance  to 
the  body. 

A  previous  injury  to  the  valves  is  an  important  factor  in 
determining  their  invasion  by  the  bacteria  which  have  gained  access 
to  the  circulation.  Consequently  infective  endocarditis  usually 
attacks  a  patient  who  is  suffering  from  old  or  even  recent  valvular 
disease.  Nevertheless,  in  some  cases  a  previously  healthy  heart 
may  be  attacked.  The  valves  on  the  left  side  of  the  heart — the 
aortic  and  mitral — are  the  parts  most  frequently  affected,  either  one 
or  the  other,  or  both.  Occasionally  the  valves  on  the  right  side 
are  affected,  though  much  oftener  than  from  simple  endocarditis, 
and  very  rarely  there  is  mural  endocarditis  without  lesion  of  the 
valves. 

The  inflammation  of  the  endocardium  leads  to  the  formation  of 
"  vegetations  "  of  a  grayish  colour,  which  may  be  small,  or  may  form 
large  fungating  masses.  A  section  through  the  lesion  shows  that 
it  consists  of  a  round-celled  infiltration.  The  tissue  on  the  surface 
of  the  valve  undergoes  coagulative  necrosis,  and  a  layer  of  fibrin 
is  deposited  upon  it  from  the  blood.  In  the  fibrin  and  necrosed 
tissue,  and  to  a  less  extent  between  the  cells,  are  found  the  bacteria, 
which  are  the  cause  of  the  inflammation.  Ulceration  frequently 
occurs,  and  this  may  be  so  extensive  as  to  cause  perforation 
of  a  valve  or  separation  of  a  large  segment.  In  some  cases  .a 
deep  ulceration  at  the  base  of  a  valve  may  lead  to  aneurysmal 
bulging.  The  lesions  in  the  endocardium  differ  from  those  of 
simple  acute  endocarditis  in  containing  bacteria,  in  the  tendency  to 
necrosis  and  ulceration,  and  in  the  absence  of  reparative  processes. 
The  effects  of  infecti%-e  endocarditis  upon  the  patient  are  of  two 
kinds,  the  one  being  due  to  the  mechanical  injury  to  the  valves,  and 
the  other  to  the  injurious  influence  of  the  bacteria.  Valvular  in- 
competency caused  by  infective  endocarditis  produces  the  same  effect 
upon  the  heart  and  the  other  organs  as  does  valvular  incompetency 
caused  by  simple  endocarditis,  i.e.  h}-pertrophy  and  dilatation  of  the 
heart,  congested  liver,  oedema,  and  other  effects  of  "  backward 
pressure." 

The  bacteria  give  rise  to  the  usual  effects  of  septicaemia,  "cloudy 
swelling  "  of  the  cells  of  the  organs,  haemorrhages  into  the  skin  and 
other  parts,  acute  haemorrhagic  nephritis,  etc.  Emboli  are  frequently 
carried  from  the  heart  to  distant  parts.      If  the  embolus  contains 


INFECTIVE  ENDOCARDITIS  79 

bacteria  it  causes  inflammatory  changes  where  it  lodges.  The 
lungs,  spleen,  liver  and  kidneys  may  thus  be  riddled  with  small 
abscesses  similar  to  those  met  with  in  pysemia,  and  haemorrhagic 
patches  of  inflammation  may  be  found  in  the  intestines.  The  effect 
of  a  septic  embolus  in  a  medium-sized  artery  may  be  to  cause 
ulceration  of  the  wall,  which  yields  to  the  pressure  of  the  blood,  and 
thus  a  small  aneurysm  is  produced.  If  the  embolus  should  be  free 
from  bacteria  the  same  effects  are  produced  as  in  the  case  of  simple 
endocarditis,  i.e.  infarcts  in  the  spleen,  kidneys,  and  lungs,  cerebral 
softening,  etc. 

It  will  thus  appear  that  a  large  number  of  lesions  may  be  found 
at  a  post-mortem  examination  of  the  body  of  a  patient  dying  of 
infective  endocarditis.  It  is  also  not  uncommon  for  a  secondary 
lobar  pneumonia  to  develop  during  the  last  few  days  of  life. 

With  regard  to  the  distribution  of  the  bacteria  through  the  body, 
they  may  be  found  in  small  numbers  in  all  the  organs  and  in  the 
blood ;  but,  as  a  rule,  they  are  limited  to  the  affected  valves,  and 
to  the  secondary  lesions  in  the  organs,  where  they  are  present  in 
abundance. 

The  symptoms  of  the  disease  may  be  divided  into  two  broad 
groups — cardiac  and  septic — sometimes  the  one  and  sometimes  the 
other  predominating.  It  will  be  unnecessary  to  detail  here  all  the 
symptoms  that  may  arise ;  it  will  be  sufficient  to  mention  the  more 
important,  a  fuller  description  of  those  directly  due  to  the  heart 
being  set  forth  elsewhere. 

The  cardiac  symptoms  comprise  the  usual  manifestations  due 
to  valvular  disease,  dyspnoea,  dropsy,  albuminuria,  enlargement  of 
the  liver  and  spleen,  etc.  On  account  of  the  progress  of  the 
endocarditis,  the  bruits  are  apt  to  change  somewhat  rapidly  in 
character  and  fresh  ones  may  develop.  The  partial  detachment 
of  a  valve  may  give  rise  to  a  high-pitched  or  musical  bruit. 

The  septic  symptoms  include  pyrexia,  which  may  be  continuous, 
but  is  much  more  frequently  intermittent  and  accompanied  by 
rigors ;  profuse  sweating ;  petechiae  and  haemorrhages  into  the  skin, 
the  mucous  membranes,  and  the  retinae ;  the  presence  of  blood, 
albumen,  granular  and  epithelial  casts  in  the  urine  ;  and  perhaps 
evidence  of  suppuration  in  the  lungs,  abdominal  viscera,  the  joints, 
or  the  meninges  of  the  brain. 

The  occurrence  of  an  embolism  may  give  rise  to  the  charac- 
teristic symptoms  of  infarction.  If  a  branch  of  the  splenic  artery 
is  blocked,  the  spleen  becomes  enlarged  and  tender ;  if  the  middle 
cerebral  artery  is  blocked,  hemiplegia  occurs ;  and  if  a  branch   of 


So  MANUAL   OF  MEDICINE 

ihe  pulmonary  artery  is  occluded,  pulmonary  apoplexy  arises,  causing 
haemoptysis  and  signs  of  consolidation  of  the  lung.  Should  the 
embolus  contain  bacteria  it  will  set  up  septic  inflammation  in  the 
part  in  addition  to  its  mechanical  effect. 

Certain  clinical  types  of  the  disease  may  be  recognised,  but  it 
would  be  unwise  to  attempt  to  draw  a  too  definite  line  of  demarca- 
tion between  them.  These  types  are  the  cardiac,  the  septic  or 
pyaemic,  and  the  cerebral. 

In  the  cardiac  type  the  infective  process  is  engrafted  upon  an 
old  valvular  disease.  A  patient  who  has  been  suffering  for  some 
time  with  cardiac  symptoms  begins  to  manifest  pyrexia,  and  be- 
comes aucemic.  For  some  days,  or  even  weeks,  the  causation 
of  the  pyrexia  may  remain  obscure,  but  after  a  time  other  symptoms 
develop  which  point  to  the  nature  of  the  case.  The  spleen  perhaps 
becomes  enlarged  and  tender ;  petechiae  appear  in  the  skin  ;  blood 
and  casts  appear  in  the  urine ;  or  the  pyrexia  assumes  a  septic  type 
with  rigors  and  profuse  sweating.  The  cardiac  symptoms  undergo 
aggravation,  and  embolism  may  occur.  The  patient  gradually  fails, 
and  usually  dies  after  some  months  from  the  combined  effects  of 
the  cardiac  affection  and  of  septicaemia. 

The  septic  or  pyce7)iic  type  may  occur  in  patients  suffering  from 
old  cardiac  mischief,  or  in  those  with  hearts  previously  healthy.  In 
either  case  the  septic  symptoms  are  the  most  prominent  feature 
of  the  attack,  the  cardiac  symptoms  remaining  in  the  back- 
ground. If  the  heart  was  previously  healthy,  bruits  indicative  of 
lesions  of  the  infected  valves  generally  develop  sooner  or  later,  but 
in  some  rapidly  fatal  cases  no  evidence  of  cardiac  affection  is  forth- 
coming during  life.  The  principal  symptom  is  severe  fever  with 
rigors  and  sweating.  Haemorrhages  frequently  appear  in  the  skin, 
the  retinae,  and  the  mucous  membranes.  Blood  and  casts  appear 
in  the  urine.  The  joints  may  suppurate  and  there  may  be  cough 
with  blood-stained  sputum.  The  spleen  is  usually  enlarged.  There 
are  the  usual  symptoms  of  high  fever,  a  rapid  pulse,  a  dry  brown 
tongue,  hurried  respiration,  delirium,  diarrhoea,  and  so  on.  Such 
cases  usually  take  a  rapid  course,  the  patient  dying  in  a  few  weeks 
after  the  onset.  In  some  cases  the  pyrexia  is  continuously  high, 
105°  or  higher,  and  the  patient  falls  into  a  "typhoid  state,"  so  that 
a  typhoid  type  has  been  described,  but  such  a  distinction  seems  to 
be  unnecessary. 

In  the  cerebral  type  the  principal  symptoms  are  cerebral,  con- 
vulsions, headache,  etc. ;  and  in  these  cases  meningitis  is  usually 
present. 


INFECTIVE   ENDOCARDITIS  gi 

The  prognosis  of  infective  endocarditis  is  always  grave.  The 
majority  of  cases  end  fatally.  Nevertheless,  recovery  may  ensue 
with  permanent  injury  to  the  valves.  In  many  cases  the  patient 
apparently  recovers,  but  after  some  time — it  may  be  months — a 
fatal  relapse  occurs. 

The  diagnosis  of  infective  endocarditis  is  often  difficult.  Con- 
tinued pyrexia  arising  in  the  subject  of  old  cardiac  disease  should 
always  be  regarded  with  suspicion,  but  until  more  definite  symptoms 
arise  a  diagnosis  can  hardly  be  made.  In  addition  to  pyrexia  the 
most  important  symptoms  for  diagnostic  purposes  are  petechiee  in 
the  skin,  the  presence  of  blood  and  casts  in  the  urine,  and  tender- 
ness and  enlargement  of  the  spleen.  Profound  ansmia  is  also  a 
sign  of  some  value. 

In  the  septic  type  of  the  disease  the  cardiac  symptoms  may  be 
so  slight  that  a  diagnosis  from  septicsemia  is  impossible.  This, 
however,  is  a  matter  of  but  little  importance ;  for  we  must  regard 
the  affection  of  the  endocardium  as  an  accidental,  rather  than  an 
essential  feature  of  this  type  of  the  disease.  The  occurrence  of 
embolism  and  the  development  of  cardiac  bruits  render  the 
diagnosis  clear. 

In  any  case  the  discovery  of  some  source  of  infection,  such  as  a 
previous  pneumonia,  or  a  septic  wound,  should  aid  in  forming  an 
opinion,  but  it  must  be  remembered  that  a  primary  lesion  is  by 
no  means  always  to  be  detected. 

Perhaps  typhoid  fever  is  the  disease  most  frequently  mistaken 
for  infective  endocarditis.  The  tumidity  of  the  abdomen,  the 
presence  of  spots,  and  the  temperature  curve  in  the  former,  and  the 
occurrence  of  emboli,  a  petechial  eruption,  and  cardiac  bruits  in  the 
latter,  are  distinguishing  features.  Rigors  are  much  more  frequent 
in  infective  endocarditis  than  in  typhoid  fever.  In  doubtful  cases 
the  blood  should  be  tested  for  the  "typhoid  reaction,"  which,  if 
present,  is  almost  absolutely  distinctive. 

A  bacteriological  examination  of  the  blood  in  infective  endo- 
carditis may  enable  us  to  say  what  bacteria  are  causing  the  infection. 
But  unfortunately  for  diagnostic  purposes  the  bacteria  are  usually 
absent  from  the  circulating  blood,  and  at  the  best  are  only  present 
in  very  small  numbers  during  life ;  consequently  the  examination 
frequently  fails  to  reveal  their  presence.  The  best  prospect  of 
success  is  to  examine  a  large  quantity  of  blood — five  or  ten  cubic 
centimetres.  Such  a  quantity  can  readily  be  obtained  by  means  of 
a  sterile  syringe  from  one  of  the  superficial  veins  in  the  arm. 

In  the  treatment  of  ulcerative  endocarditis,  quinine,  arsenic, 

VOL.  I  G 


82  MANUAL  OF  MEDICINE 

and  sulpho-carbolates  have  in  some  cases  appeared  to  be  beneficial, 
and  when  there  is  high  fever  the  usual  antipyretics  may  be  ad- 
ministered. If  we  have  evidence,  either  from  the  source  of  infection 
or  from  a  bacteriological  examination,  that  the  endocarditis  is  due 
to  the  streptococcus  pyogenes,  antistreptococcic  serum  should  be 
administered.  In  one  case  under  the  care  of  the  writer,  the  daily 
administration  of  the  serum  for  some  weeks  apparently  led  to  the 
recovery  of  the  patient.  An  antipneumococcic  serum  will  probably 
be  found  useful  in  cases  caused  by  the  pneumococcus. 

J.  W.  Washbourn. 


GONORRHCEAL    INFECTION 

In  addition  to  the  urethral  discharge  and  those  more  immediate 
complications  which  are  treated  of  in  surgical  works,  gonorrhoea  is 
not  unfrequently  accompanied  or  followed  by  affections  of  distant 
parts,  and  occasionally  of  internal  organs.  The  structures  most 
commonly  affected  are  the  joints,  tendons,  and  fasciae,  while  less 
frequently  observed  or  diagnosed  as  specifically  gonorrhoeal  are 
such  complications  as  iritis,  conjunctivitis,  sclerotitis,  myositis, 
pleuritis,  neuritis,  meningomyelitis,  endocarditis,  and  arteritis.  In 
some  instances  of  these  metastatic  or  secondary  inflammations  the 
presence  of  the  gonococcus  has  been  demonstrated  and  the  fact  of 
their  specific  origin  established.  The  infection  is,  therefore,  on 
septicsemic  lines,  that  is  to  say,  the  specific  organism  finds  its  way  to 
distant  parts  through  the  blood  or  lymph  channels,  and  having 
arrived  at  its  ultimate  destination,  excites  secondary  local  mischiefs. 
It  is  possible,  however,  that  the  circulation  of  gonotoxin  is  re- 
sponsible for  at  least  some  of  the  symptoms  and  phenomena  of 
secondary  gonorrhceal  infection.  In  this  connection  it  may  be 
mentioned  that  the  infection  may  be  acquired  accidentally  or 
imparted  experimentally  either  by  inoculation  with  gonorrhoeal 
discharge,  e.g.  on  the  conjunctiva,  or  by  means  of  pure  cultures  of 
the  coccus. 

Of  these  secondary  infections  by  far  the  most  common  or  most 
noticed  is  arthritis.,  so  much  so  that  "  gonorrhoeal  rheumatism  "  so- 
called  was  until  quite  recently  the  recognised  term  used  to  express 
the  generalisation  of  the  gonorrhoeal  virus.     Though  any  and  every 


GONORRHCEAL  INFECTION  83 

joint  may  suffer,  those  most  frequently  attacked  are  the  knees,  after 
which  come  the  ankle  and  wrist  joints,  then  those  of  the  elbow, 
hands,  and  feet,  and  the  sterno-clavicular,  temporo-maxillary,  and 
sacro-iliac. 

The  affection  may  commence  at  any  time  in  the  course  of  the 
urethral  discharge,  whether  the  flux  be  in  the  acute  or  chronic 
stage.  Thus  it  may  manifest  itself  a  few  days  after  the  first  appear- 
ance of  the  discharge,  or  not  until  this  has  been  existing  for  weeks, 
and  sometimes  sets  in  after  the  complete  disappearance  of  the 
urethritis. 

Sjrmptoms. — As  a  rule  the  arthritis  appears  suddenly,  and  is 
marked  by  swelling  of  a  joint  or  joints,  often,  but  not  always,  with 
redness  of  the  skin  over  them,  and  pain  and  tenderness,  frequently 
worse  at  night.  The  swelling  is  due  to  exudation  not  only  into,  but 
around  the  joint  or  tendon  (periarthritis).  The  onset  may  be  associ- 
ated with  constitutional  symptoms,  such  as  pyrexia,  furred  tongue, 
malaise,  general  pains,  and  other  febrile  phenomena.  These  general 
symptoms,  however,  may  be  absent  or  but  little  marked,  more 
especially  if  the  arthritis  supervene  when  the  more  active  stage  of 
the  discharge  has  passed  away.  The  pain,  though  it  may  be  severe, 
is  usually  of  a  dull,  aching  character.  Inspection  of  an  affected 
joint  or  tendon  usually  indicates  the  presence  of  effusion  into  the 
joint  or  within  the  sheath,  and  while  palpation  confirms  this,  it 
invariably  imparts  the  notion  of  exudation  into  the  capsule  or  the 
sheath  and  the  adjacent  parts.  This  condition  lasts  for  some  time, 
usually  weeks,  or  even  months,  and  the  subsidence  of  the  swelling 
is  almost  invariably  accompanied  by  weakness  and  stiffness  of  the 
joint.  The  stiffness,  partly  due  to  exudation  into  the  capsule  of 
the  joint  and  partly  to  adhesions,  may  in  severe  cases  terminate  in 
ankylosis  and  chronic  osteo -arthritic  changes.  Though  stiffness 
and  ankylosis  of  joints  are  not  uncommon  sequelae,  suppuration  is 
rare,  and  its  occurrence  may  be  regarded  as  indicating  a  mixed 
infection. 

The  arthritis  may  be  multiple  and  is  often  symmetrical,  as  seen 
in  affection  of  both  knees,  ankles,  or  hands,  but  this  is  by  no  means 
always  the  case,  for  the  inflammation  may  be  limited  to  one  joint, 
tendon,  or  fascia  of  one  side,  and  this  is  m.ore  common  in  the 
knee  and  elbow.  As  a  general  rule,  when  the  inflammation  has 
subsided  in  the  affected  part  there  is  little  tendency  to  recurrence, 
unless  there  be  a  simultaneous  recrudescence  of  the  discharge  or 
the  patient  again  contract  a  gonorrhoea. 

Inflammations  of  tendons  and  their  sheaths,  of  fasciae,  especially 


84  MANUAL  OF  MEDICINE 

of  the  back,  of  the  thigh,  and  of  the  soles  of  the  feet,  are  quite 
common  as  comphcations  of  gonorrhoea,  and  what  has  been  said 
with  regard  to  joints  will  equally  well  apply  to  them. 

Though  arthritis  and  synovitis  are  by  far  the  most  frequent 
expressions  of  generalised  gonorrhoea!  infection,  yet  the  other  com- 
plications already  enumerated  should  not  be  lost  sight  of.  During 
the  onset  of  gonorrhoea!  arthritis  the  patient  may  suffer  from 
catarrhal  ophthalmia,  sometimes  accompanied  by  iritis  and  sclero- 
titis. The  injection  of  the  sclerotic,  which  is  quite  distinct  from 
the  gonorrhoeal  ophthalmia  due  to  direct  infection  with  the  urethral 
discharge,  is  regarded  by  some  as  almost  pathognomonic  of 
gonorrhoeal  arthritis  in  adults.  Of  recent  years  attention  has  been 
called  to  more  severe  and  important  complications,  such  as 
pleuritis,  peri-  and  endo  -  carditis,  and  though  affection  of  the 
heart  is  regarded  as  a  symptom  diagnostic  of  "  rheumatism,"  it 
has  been  rendered  certain  that  valvulitis  may  be  the  result  of 
gonorrhoea,  indeed  one  such  case  was  followed  by  gangrene  of 
one  of  the  lower  limbs,  presumably  embolic  in  nature.  The  writer 
has  for  years  expressed  the  opinion  that  many  examples  of  chronic 
arteritis,  especially  some  cases  of  atheroma  of  the  aorta,  are  in  all 
probability  due  to  gonorrhoea.  Cases  of  myositis,  neuritis,  and 
meningo-myelitis  as  complications  or  sequelae  of  gonorrhoea  have 
been  recorded.  In  the  character  of  its  complications  it  will  be 
noted  that  gonorrhoea  closely  resembles  other  specific  infections. 

In  most  cases  the  prognosis  is  favourable,  but  the  course  of 
the  disorder  is  not  unfrequently  lengthy  and  tedious.  There  is, 
however,  little  tendency  to  relapse  or  recrudescence.  There  is 
always  the  possibility  of  permanent  stiffness,  and  even  of  ankylosis, 
to  be  reckoned  with,  while  the  occurrence  of  damage  to  vital  organs 
should  be  borne  in  mind.  Death  with  hyperpyrexia  has  been  known 
to  occur. 

The  diagnosis  of  the  arthritis,  or  other  secondary  morbid 
development,  must  principally  depend  on  the  coexistence  or  recent 
occurrence  of  a  gonorrhoeal  discharge.  The  evidence  to  be  derived 
from  a  bacterioscopic  examination  of  the  urethral  or  vaginal  discharge 
is  of  less  practical  value  than  might  be  hoped ;  for  in  the  earlier 
stages  there  is  little  need  for  such  confirmation,  and  in  the  later 
or  chronic  stages  there  is  much  difficulty  in  demonstrating  the 
gonococcus.  Still,  it  might  have  a  negative  value  in  cases  of  gouty 
urethritis  and  balanitis  associated  with  arthritis. 

The  remote  results  of  gonorrhoeal  infection,  arthritic  and  other, 
are  met  with  in  both  sexes,  though  probably  with  greater  frequency 


GONORRHCEAL  INFECTION  85 

in  the  male.  Difficulties,  due  to  ignorance  or  purposed  conceal- 
ment, frequently  arise  in  connection  with  obtaining  precise  knowledge 
in  the  case  of  females.  The  various  manifestations  predominate  in 
young  adult  life,  but  may  be  met  with  at  all  previous  ages.  In 
females  the  coexistence  of  chronic  uterine  affection,  vaginal  dis- 
charge, and  arthritis  may  suggest  the  real  nature  of  the  disease. 

The  conjunction  of  ophthalmia  and  arthritis  is  almost  sufficient 
evidence  in  itself  of  gonorrhoeal  infection.  It  is  in  this  form  that 
the  disease  manifests  itself  in  infants.  Inoculation  of  the  conjunc- 
tiva takes  place  at  birth,  a  few  days  after  which  the  ophthalmia 
appears,  to  be  followed  in  two  or  three  weeks  by  the  arthritis.  Even 
in  such  cases  there  is  the  same  preference  exhibited  by  the  knees  as 
seen  in  adults,  and  the  general  features  of  the  joint  affection  corre- 
spond to  the  above  description.  In  very  young  subjects  the  disease 
seems  to  be  more  amenable  to  treatment,  and  to  run  a  course  of  a 
few  weeks  only,  without  the  obstinate  persistence  so  characteristic 
of  its  occurrence  in  the  grown  up.  In  older  children  the  affections 
of  the  joints,  tendons,  or  fasciae  may  follow  on  accidental  conjunct 
tival  inoculation  or  criminal  vulvo-vaginal  infection. 

The  affection  of  certain  joints,  such  as  the  sterno-clavicular, 
sacro-iliac,  and  temporo-maxillary,  which  are  less  frequently  attacked 
in  ordinary  rheumatism,  should  give  rise  to  suspicion.  Though 
gonorrhoeal  arthritis  is  not  unfrequently  polyarticular,  it  exhibits 
less  tendency  than  articular  rheumatism  to  shift  from  one  joint  (or 
joints)  to  another. 

Treatment. — No  specific  to  abbreviate  the  tedious  and  pro- 
tracted course  of  the  disease  has  yet  been  discovered.  The  treatment 
must  be  palliative,  symptomatic,  and  chiefly  on  surgical  lines ; 
indeed  the  very  story  of  the  disaster  clearly  indicates  that  any 
urethral  discharge  should  receive  special  attention.  Painting  a 
joint  or  tendon  very  freely  with  liq.  iodi  fort,  sometimes  has  a 
good  effect,  while  the  withdrawal  of  fluid  from  joints  which  exhibit 
little  tendency  to  resolution  and  irrigation  with  a  solution  (i  in 
4000)  of  perchloride  of  mercury  is  to  be  recommended.  In  some 
cases  the  application  of  belladonna  or  of  Scott's  dressing  is  useful. 
It  may  be  necessary  to  apply  splints  in  the  acute  stage  to  keep  the 
joints  at  rest,  and  afterwards  to  use  friction  or  massage,  which  may 
be  advantageously  combined  with  the  local  application  of  dry  heat. 
Sometimes  it  is  necessary  to  break  down  adhesions  under  an 
anaesthetic.  Should  any  of  the  more  serious  complications  of  the 
infection  manifest  themselves,  e.,i,':  pleurisy,  pericarditis,  or  endo- 
carditis, these  must  be  treated  on  appropriate  lines.    The  diet  should 


86  MANUAL   OF   MEDICINE 

be  nutritious  and  not  too  stimulating;  the  bowels  must  be  carefully 
regulated.  For  the  pain,  it  is  best  to  rely  on  opium  or  morphia. 
The  most  approved  internal  remedies  are  quinine,  with  potassium 
iodide  and  arsenic,  though  occasionally  guaiacum  and  sarsaparilla 
seem  to  do  good.  Ordinary  anti-rheumatic  remedies,  such  as  the 
salicylates,  have  no  effect. 

R.   G.  Hebb. 


TYPHOID    FEVER 
Syn.  Enteric  Fever 

An  infectious  fever  characterised  by  inflammation  and  sloughing 
of  the  solitary  and  agminate  glands  of  the  small  intestine,  enlarge- 
ment of  the  mesenteric  glands  and  spleen,  and  a  roseolous  rash. 
The  disease  is  caused  by  the  invasion  of  a  specific  microbe — the 
bacillus  typhosus,  or  Ebertlis  bacillus. 

Bacteriology. — The  bacillus  typhosus  is  a  flagellated  bacillus 
usually  2  /i,  to  4  /A  long  and  0.5  /x.  thick.  In  liquid  media  it  shows 
active  movements  (Plate  I.).  It  presents  a  very  close  resemblance  both 
in  structure  and  habit  to  the  bacillus  coli  cojmnunis,  from  which,  how- 
ever, it  is  specifically  distinct.  It  may  readily  be  cultivated  in  the 
usual  artificial  media,  both  liquid  and  soHd,  in  which  it  multiplies 
freely.  It  flourishes  best  at  about  the  temperature  of  the  body,  37°  C. 
(98.6"  F.).  It  ceases  to  grow  below  9°  C.  (48.2°  F.),  or  above  42°  C. 
(107.6°  F.).  It  is  killed  by  a  few  minutes'  exposure  to  the  boiling 
point,  or  by  half-an-hour's  exposure  to  a  temperature  of  60°  C. 
(140°  F.).  It  will  maintain  its  vitality  for  a  considerable  time,  many 
days  or  even  weeks,  in  water  both  fresh  and  salt,  especially  when 
sterilised,  but  it  does  not  multiply  in  water.  It  will  also  maintain 
its  vitality  for  many  weeks  when  mixed  with  sand  or  earth  and  dried, 
and  may  then  be  blown  about  as  dust.  In  soils  contaminated  with 
animal  matter  it  will  continue  to  grow  and  spread  indefinitely  at 
the  ordinary  temperature  of  the  air,  but  in  virgin  soils  it  dies  out. 
Exposure  to  sunlight  impairs  its  vitality.  It  has  been  found  alive 
in  the  pallial  cavity,  and  in  the  rectum  of  oysters  and  other  bivalve 
molluscs  living  in  water  contaminated  with  sewage,  and  it  has  been 
found  to  be  capable  of  penetrating  eggs  immersed  in  liquid  cultures, 


TYPHOID   FEVER  87 

It  grows  freely  in  milk  and  butter.  When  cultivated  in  artificial 
media  it  very  rapidly  loses  its  virulence,  which  can  be  restored  and 
intensified  to  the  highest  pitch  by  passing  it  through  the  peritoneal 
cavity  of  successive  animals. 

When  cultivated  the  bacillus  generates  poisons  which  are  both 
contained  in  its  substance  and  diffused  in  the  medium.  These 
present  some  differences  of  action,  but  generally  when  injected  into 
the  animal  body  they  cause  fever,  followed  by  collapse,  injection  of 
the  mucous  membrane  of  the  intestine,  mucous  diarrhoea,  and  fatty 
degeneration  of  the  heart.  The  bacillus  itself,  when  introduced 
either  into  the  peritoneal  cavity  or  subcutaneously,  is  capable,  when 
virulent,  of  becoming  diffused,  and  may  be  found  in  the  blood, 
spleen,  liver,  and  other  internal  organs,  but  shows  no  predilection 
for  the  intestinal  glands,  and  does  not  produce  the  specific  intestinal 
lesions  of  human  typhoid,  though  the  poisons  generated  by  it 
cause  intestinal  injection  and  diarrhoea,  as  do  those  of  many 
other  pathogenetic  organisms.  So  that  it  is  possible  in  the  human 
subject  for  the  symptoms  of  enteric  fever  to  occur  without  intestinal 
lesions  being  found  on  post-mortem  examination  ;  and  such  cases 
have  been  reported.  It  was  for  a  long  time  doubtful  whether  the 
lower  animals  were  capable  of  acquiring  the  human  form  of  typhoid, 
recently,  however,  Remling  appears  to  have  succeeded  with  rabbits 
and  rats  by  giving  intensely  virulent  cultures  with  the  food,  and  so 
produced  infiltration  and  ulceration  of  the  agminate  glands.  It 
would  appear,  therefore,  that  in  the  human  subject  the  bacillus  is 
introduced  by  swallowing,  and  that  the  intestinal  glands  are  primarily 
affected  as  being  the  seat  of  absorption  and  not  secondarily  as  the 
result  of  a  blood  infection. 

In  man  the  typhoid  bacillus  occurs  in  the  inflamed  intestinal  and 
mesenteric  glands  ;  in  the  spleen ;  less  abundantly  in  the  intestinal 
contents  and  the  faeces  ;  it  has  also  been  found  in  the  liver,  the 
bile,  the  urine,  the  blood,  the  cerebral  meninges  and  ventricles,  and 
in  secondary  abscesses  of  distant  parts  where  it  has  been  found  still 
alive,  even  as  long  as  seven  years  after  the  attack.  It  is,  therefore, 
evident  that  though  chiefly  located  at  the  seats  of  absorption  it 
becomes  more  or  less  diffused  through  the  system.  It  does  not 
usually  cause  suppuration,  and  the  secondary  abscesses  are  mostly 
due  to  pyogenic  microbes,  but  in  some  cases  these  abscesses  have 
been  found  absolutely  sterile  as  regards  other  than  the  typhoid 
organisms. 

Etiology. — First  to  be  considered  are  {a)  the  conditions  which 
favour  the  multiplication  of  the  bacillus  and  facilitate  its  entrance  j 


88  MANUAL  OF  MEDICINE 

and,  secondly,  (^)  those  which  affect  the  susceptibihty  of  the  in- 
dividual. 

(a)  We  may  regard  the  bacillus  either  as  a  saprophyte  which 
naturally  lives  in  soil  contaminated  by  animal  matter,  but  which  is 
capable  of  becoming  parasitic  when  it  obtains  entrance  into  the 
body — a  facultative  parasite  ;  or  more  probably  as  an  organism  which 
only  obtains  its  full  development  and  properties  in  the  animal  body, 
but  which  can  maintain  an  existence  outside — a  facultative  sapro- 
phyte. It  is  evident  that  no  sharply-defined  line  of  demarcation 
can  be  drawn  between  these  two  classes,  but  the  question  is  im- 
portant with  regard  to  the  occurrence  of  apparently  spontaneous  or 
^e  novo  outbreaks  of  the  disease. 

The  bacillus  in  all  probability  obtains  entrance  into  the  system 
by  being  swallowed,  either  with  the  food  or  drink,  or  by  putting 
into  the  mouth  some  contaminated  object,  as,  for  instance,  a  soiled 
finger,  or  by  drawing  into  the  mouth  or  pharynx  the  germs  suspended 
in  the  air. 

The  most  common  cause  of  outbreaks  of  typhoid  is  contamina- 
tion of  the  drinking  water.  This  may  be  due  to  soakage  of  sewage 
or  feeces  into  wells,  sewage  contamination  of  rivers,  lakes,  ponds, 
springs,  reservoirs.  Permanent  infection  of  the  soil  by  the  typhoid 
bacillus  may  render  the  disease  endemic  in  a  locality,  and  give 
rise  to  outbreaks  without  any  fresh  importation  of  the  poison. 
Faulty  construction  of  cisterns,  waste  pipes,  water  closets,  will  cause 
localised  outbreaks  by  contaminating  the  house  supply. 

Milk  and  articles  of  food  containing  or  derived  from  milk,  as 
butter,  creams,  ices,  frequently  spread  the  disease.  There  is  no 
reason  for  supposing  that  the  milk  as  passed  from  the  cow  is  ever 
infected ;  in  most  cases  the  contamination  is  due  to  the  water  used 
to  wash  the  dairy  utensils,  or  which  has  been  mixed  with  the 
milk.  Not  only  does  the  bacillus  maintain  its  vitality  but  freely 
multiplies  in  milk.  Many  other  articles  of  food  which  are  eaten 
uncooked  are  liable  to  spread  the  disease,  especially  oysters  cultivated 
in  estuaries  which  receive  sewage,  water  cresses  grown  in  ditches 
contaminated  by  sewage,  lettuces,  and  other  salads  watered  with 
polluted  water.  It  is  probable  that  articles  of  food,  especially  in  hot 
countries,  may  be  contaminated  by  flies  to  whose  feet  the  typhoid 
germs  may  easily  adhere.  Outbreaks  of  typhoid  have  been  ascribed 
to  eating  diseased  meat,  but  some  doubt  exists  as  to  the  exact  nature 
of  the  disease  in  these  outbreaks.  In  a  recent  one  a  specific  bacillus, 
closely  resembling  but  distinct  from  the  typhoid  bacillus,  the  bacillus 
enteritidis  of  Gartner,  was  discovered. 


TYPHOID   FEVER  89 

Typhoid  fever  may  also  be  acquired  through  aerial  infection,  by 
inhalation  of  emanations  from  drains,  sewers,  water  closets,  privies, 
dust  heaps,  faecal  discharges  which  have  been  allowed  to  dry  on  the 
patient's  linen  or  person,  or  in  receptacles.  Probably  in  these  cases 
the  bacillus  has  become  dried  and  disseminated  as  dust,  but  experi- 
ments have  shown  that  a  very  slight  current  of  air,  4  metres  per 
second,  will  raise  germs  into  the  atmosphere  from  the  surface  of 
liquids  or  wet  ground,  and  a  current  of  30  metres  per  second  from 
dry  surfaces.  It  is  not,  however,  probable  that  any  distant  infection 
can  take  place  in  this  manner,  as  free  dilution  with  air  renders  the 
virus  inert. 

Direct  contagion  from  the  sick  to  the  healthy  plays  but  a  small 
part  in  the  spread  of  the  disease.  There  is  no  reason  to  suppose 
that  the  poison  is  given  off  in  the  breath  or  emanations  from  the 
body,  but  is  contained  only  in  the  fteces  and  to  a  less  degree  in  the 
urine,  and  if  these  be  properly  disinfected  and  disposed  of,  strict 
cleanliness  be  observed,  and  attention  be  paid  to  the  disinfection 
of  the  soiled  linen,  the  risk  of  contagion  may  be  reduced  to  a 
minimum.  Nevertheless,  it  has  not  been  found  possible  entirely 
to  prevent  the  spread  of  the  disease  to  the  attendants.  It  seems 
probable  that  the  alvine  discharges  are  less  virulent  when  first  passed 
than  after  the  lapse  of  some  little  time.  The  conditions  which 
favour  the  multiplication  of  the  bacillus  and  the  intensification  of 
its  virulence  outside  the  body  are  still  imperfectly  known. 

The  disease  appears  to  occur  in  all  climates,  but  is  most 
prevalent  in  temperate  and  subtropical  regions.  In  temperate 
climates  it  is  especially  an  autumnal  disease.  In  this  country 
it  is  most  prevalent  during  the  months  of  September,  October, 
November ;  least  so  in  April,  May,  and  June.  A  hot  dry  summer 
increases  the  autumnal  prevalence.  Great  importance  was  attached 
by  Pettenkofer  to  the  height  of  the  ground  water,  a  low  ground 
water  coinciding  with  outbreaks  of  the  disease ;  whether  this  be  due 
to  this  condition  favouring  the  contamination  of  the  water  supply, 
or  to  its  facilitating  soil  pollution  and  the  rising  of  the  germs  into  the 
air  is  uncertain.  In  England  this  relation  of  the  height  of  the 
ground  water  to  outbreaks  of  the  disease  has  not  been  observed. 

(b)  The  conditions  affecting  the  susceptibility  of  the  individual 
are  as  follows  : — 

Typhoid  fever  occurs  at  all  ages,  but  is  most  frequent  between 
five  and  thirty -five.  Exceptional  cases  have  been  met  with  as 
young  as  three  months,  and  as  late  as  seventy  years.  It  is  equally 
common    in   both  sexes,  and  attacks  persons  in  all  ranks  of  life. 


90  MANUAL  OF  MEDICINE 

One  attack  confers  immunity,  though  not  an  absolute  one,  against 
a  second.  New-comers  into  infected  localities  are  generally  con- 
sidered to  be  more  susceptible  than  old  residents ;  probably  these 
have  been  rendered  more  or  less  immune  by  repeated  slight  in- 
fections. In  India,  where  the  disease  is  extremely  common  and 
fatal  among  the  English  sojourners,  especially  the  new-comers,  the 
natives  used  to  be  regarded  as  very  little  susceptible,  but  recently 
the  observations  of  Major  Frazer,  M.D.,  founded  on  Widal's  test, 
tend  to  show  that  this  immunity  of  the  native  population  is  due  to 
a  large  proportion  of  them  having  been  attacked  in  early  childhood, 
when  the  disease  is  rarely  fatal.  European  troops,  when  campaign- 
ing in  tropical  and  subtropical  climates,  are  very  subject  to  typhoid, 
but  the  causes  of  this  prevalence  are  still  obscure. 

Morbid  anatomy. — Together  with  the  lesions  due  to  the 
typhoid  bacillus  there  are  usually  others  caused  by  other  patho- 
genetic organisms,  streptococci,  staphylococci,  etc. 

The  characteristic  typhoid  lesions  are  acute  inflammation,  usually 
terminating  in  necrosis  and  ulceration  of  the  agminate  and  solitary 
glands  of  the  small  intestine,  and  sometimes  of  the  solitary  glands 
of  the  large  bowel  ;  inflammatory  infiltration  of  the  mesenteric 
glands  ;  and  parenchymatous  swelling  of  the  spleen. 

The  changes  in  the  glands  consist  of  hyperaemia,  with  hyper- 
plasia and  exudation  of  lymphoid  cells.  The  agminate  glands  in 
this  stage  form  raised  patches  of  a  pinkish-gray  colour,  with  reticu- 
lated, rugose,  or  smooth  surfaces,  accordingly  as  the  infiltration  is 
uniform  in  all  the  tissues  of  the  patch,  or  is  greater  in  the  follicles, 
or  in  the  intervening  tissues.  This  stage  usually  attains  its  maximum 
development  in  about  ten  days.  The  solitary  glands  present  similar 
changes.  The  next  stage  consists  of  necrosis  of  many  of  the 
patches  and  solitary  glands,  the  swollen  tissues  become  converted 
into  yellowish-brown  sloughs,  the  separation  of  which,  by  a  process 
of  ulceration,  occupies  the  third  and  often  part  of  the  fourth  week. 
After  the  separation  of  the  sloughs  the  typhoid  ulcers  are  left. 
Those  corresponding  to  the  agminate  glands  are  oval  in  shape, 
their  long  diameter  corresponding  to  the  direction  of  the  intestine ; 
they  are  situated  on  the  side  of  the  bowel  opposite  to  the  attach- 
ment of  the  mesentery ;  those  corresponding  to  the  solitary  glands 
are  circular  in  shape.  The  surface  of  the  ulcers  is  smooth,  their 
edges  undermined ;  their  depth  depends  on  the  extent  of  the 
previous  inflammatory  infiltration.  The  floor  may  be  formed  by 
the  muscular  or  the  peritoneal  coat,  or  the  latter  may  itself  be  in- 
volved in  the  sloughing  process,  and  as  the  slough  separates  per- 


TYPHOID   FEVER  91 

foration  may  take  place.  As  the  ulcers  heal  the  undermined  edges 
become  adherent  to  the  subjacent  tissues,  the  surface  granulates, 
the  epithelial  covering  is  restored,  and  no  contraction  takes  place. 
This  healing  process  occupies  an  uncertain  time,  usually  a  week  or 
ten  days,  but  the  ulcers  may  pass  into  what  is  termed  an  atonic  con- 
dition and  become  chronic,  and  sometimes  even  extend  and  give 
rise  to  haemorrhage  or  perforation  when  the  patient  is  apparently 
convalescent.  These  changes  are  always  most  marked  and  most 
advanced  in  the  lower  part  of  the  ileum.  Sometimes  the  solitary 
glands  throughout  the  whole  course  of  the  large  intestine  are 
similarly  affected. 

The  mesenteric  glands  corresponding  to  the  affected  part  of  the 
intestine  become  swollen  by  cellular  hyperplasia  and  exudation,  and 
are  very  hypersemic.  Sometimes  they  soften,  break  down,  and  may 
burst  into  the  peritoneal  cavity ;  generally  resolution  takes  place, 
and  they  get  restored  to  their  normal  condition.  Occasionally  they 
become  caseous,  or  ultimately  atrophy. 

The  spleen  becomes  greatly  enlarged  from  cellular  hyperplasia 
and  hyperaemia ;  it  is  softer  and  redder  than  in  health.  With  the 
subsidence  of  the  fever  it  returns  to  its  normal  condition.  Both 
the  spleen  and  the  mesenteric  glands  contain  the  bacilli  in  large 
numbers. 

There  is  usually  more  or  less  cloudy  swelling  of  the  secreting 
cells  of  the  glandular  organs. 

The  liver  often  presents  interstitial  deposits  of  leucocytes.  In 
rare  cases  the  gall-bladder  has  been  found  ulcerated,  and  even 
perforated. 

Occasionally  there  is  parenchymatous  nephritis,  more  often  the 
renal  change  does  not  go  beyond  cloudy  swelling  of  the  epithelium. 

The  heart  is  often  softened,  the  muscular  fibres  granular,  or 
even  fatty,  and  the  striation  obscured. 

There  is  usually  hypostatic  congestion  of  the  lungs  ;  sometimes 
lobular  or  lobar  pneumonia.  Occasionally  there  are  deep  ulcers  in 
the  larynx,  usually  on  the  posterior  surface  between  the  vocal  cords, 
but  the  epiglottis  and  the  mucous  membrane  covering  the  arytaenoid 
cartilages  may  be  affected ;  these  ulcers  may  extend  to  and  cause 
necrosis  of  the  cartilages. 

Many  of  the  voluntary  muscles,  especially  the  recti  abdominis 
and  the  adductors  of  the  thigh,  often  show  the  changes  termed 
Zenker's  vitreous  degeneration,  or  myositis  typhosa,  though  they  are 
not  peculiar  to  typhoid  fever.  The  muscular  fibres  undergo  coagula- 
tion necrosis ;  they  swell  up,  lose  their  striation,  become  homogeneous, 


92  MANUAL  OF  MEDICINE 

so  as  to  resemble  cylinders  of  wax,  and  then  break  up  into  fragments 
by  transverse  fissures  and  are  absorbed ;  at  the  same  time  there  is 
an  interstitial  exudation  of  leucocytes.  If  recovery  takes  place  the 
fibres  are  regenerated  by  a  cell  growth  within  the  tube  of  sarco- 
lemma.  Sometimes  this  process  is  accompanied  by  heemorrhage 
into  the  muscle. 

Other  secondary  inflammations  and  degenerations  may  occur. 
Superficial  osteitis  causing  subperiosteal  suppuration  is  not  very 
infrequent ;  abscesses  may  form  in  various  parts  ;  venous  thrombosis, 
peripheral  neuritis,  degenerations  of  the  spinal  cord,  but  none  of 
these  are  special  to  typhoid  fever. 

Incubation. — The  usual  period  of  latency  or  incubation  after 
infection  varies  from  ten  to  fourteen  days,  but  it  may  be  as  short  as 
five,  or  as  long  as  twenty-one  days,  or  even  longer.  Usually  this 
period  is  free  from  symptoms ;  sometimes  there  is  some  degree 
of  malaise  present,  which  may  gradually  deepen  and  pass  into 
the  febrile  stage.  Occasionally  at  the  commencement  there  is 
diarrhoea,  and  sometimes,  especially  in  children,  vomiting,  these 
symptoms  subsiding  after  a  few  days. 

Symptoms  and  course. — The  onsef  of  the  disease  is  often 
somewhat  insidious,  the  patient  feels  chilly,  complains  of  languor 
and  weariness,  suffers  from  headache  and  pains  in  the  limbs,  passes 
restless  nights  with  sleep  disturbed  by  dreams,  the  tongue  is  coated, 
red  at  the  tip  and  edges.  Frequently  there  is  slight  bronchitis.  The 
temperature  rises  gradually,  often  by  regular  gradations,  a  degree 
or  more  every  successive  night,  the  morning  temperature  being  a 
degree  lower  than  the  evening  one.  These  symptoms  sometimes  con- 
tinue five  or  six  days  before  the  patient  is  compelled  by  increasing 
debility  to  take  to  his  bed.  In  other  cases  the  onset  is  more  sudden ; 
there  are  initial  rigors,  severe  headache  and  pains  in  the  back  and 
limbs,  with  rapidly  increasing  prostration,  so  that  the  patient  has  to 
lie  up  at  once. 

By  the  end  of  the  first  week  the  characteristic  symptoms  of  the 
disease  are  usually  well  marked.  The  patient  has  a  depressed 
languid  aspect ;  he  complains  of  headache,  thirst  and  general 
malaise ;  the  cheeks  often  show  a  circumscribed  pink  flush  ;  the 
pupils  are  somewhat  dilated,  but  there  is  no  injection  of  the 
sclerotics  so  often  present  in  typhus.  The  lips  are  dry  and 
parched,  often  desquamating ;  the  tongue  coated  on  the  dorsum  with 
a  white  fur,  red  at  the  tip  and  edges.  In  most  cases  the  bowels  are 
relaxed,  two  to  four  loose  light  yellow  motions,  resembling  pea-soup, 
are  passed  daily,  but  not  unfrequently  there  is  constipation,  and  the 


TYPHOID   FEVER  93 

motions  are  solid.  The  abdomen  is  usually  somewhat  distended  ; 
often  there  is  gurgling  on  palpation  in  the  right  iliac  fossa.  On 
percussion  the  spleen  is  found  to  be  enlarged,  perhaps  measuring 
five  inches  in  the  vertical  line,  but  not  usually  projecting  below  the 
costal  arch.  The  pulse  varies  from  100  to  120;  it  is  moderately 
full  but  very  compressible,  the  arterial  tone  being  low.  Often 
drawing  the  back  of  the  finger  across  the  skin  of  the  trunk  pro- 
duces a  well-marked  red  tachc  with  a  pale  border.  The  iemperattire 
varies  from  102°  to  104°  at  night,  and  is  a  degree  or  less  in  the 
morning,  but  it  is  very  labile,  i.e.  easily  affected  by  transient  con- 
ditions. The  skifi  is  dry,  but  occasional  perspirations  are  not  in- 
frequent. Sometimes  there  is  a  slight  general  febrile  blush,  and  as 
the  throat  is  often  dry  and  a  little  reddened,  and  the  tongue  also 
red,  a  suspicion  of  scarlatina  may  be  excited.  Occasionally  there  is 
epistaxis,  which  may  be  very  profuse  and  occur  at  any  period  of 
the  fever. 

The  characteristic  rash  of  typhoid  usually  makes  its  appearance 
between  the  seventh  and  twelfth  days,  but  may  be  seen  as  early  as 
the  fifth,  or  delayed  till  the  fourteenth  day  or  later.  The  rash  con- 
sists of  slightly  elevated  circular  papules  of  a  rose  colour,  which  dis- 
appear with  pressure  and  reappear  when  the  pressure  is  removed  ; 
their  number  varies  greatly ;  there  may  be  only  three  or  four  visible 
on  the  abdomen,  or  they  may  be  thickly  scattered  over  the  trunk 
and  extend  to  the  limbs,  and  in  rare  cases  they  are  seen  on  the  face. 
They  have  a  circular  outline,  and  are  regular  in  form,  measuring 
two  or  three  lines  in  diameter.  When  the  rash  is  very  intense,  they 
may  be  darker  in  colour  and  persist  on  pressure,  owing  to  some 
effusion  of  the  colouring  matter  of  the  blood,  but  they  never  become 
converted  into  petechiae.  Occasionally  a  minute  vesicle  forms  on 
them.  They  are  developed  in  successive  crops,  each  spot  lasting 
three  or  four  days,  and  the  total  duration  of  the  eruption  is  usually 
from  ten  to  twenty-one  days,  less  in  children,  but  they  may  con- 
tinue to  come  out  during  convalescence,  and  usually  recur  when  a 
relapse  takes  place.  The  rash  is  not  invariably  present,  especially 
before  the  age  of  ten  or  after  that  of  thirty.  There  is  no  necessary 
connection  between  the  amount  of  the  rash  and  the  severity  of  the 
attack. 

Pale  bluish  spots  are  occasionably  visible,  which  are  not  raised 
and  do  disappear  on  pressure,  the  tache  bleuatre  of  Trousseau. 
Their  most  frequent  seat  is  the  abdomen  and  thighs  ;  they  have 
been  attributed  to  lice,  but  are  not  necessarily  associated  with  them! 

Sometimes,  as  in  other  infectious  fevers,  the  disease  assumes  a 


94  MANUAL  OF  MEDICINE 

hsemorrhagic  form  and  purpuric  spots  appear  on  the  skin,  and  there 
may  be  haemorrhages  from  the  mucous  membranes.  Though  the 
prognosis  in  these  cases  is  unfavourable,  nevertheless  recovery  may 
take  place. 

The  iirine  presents  the  usual  characters  of  febrile  urine :  it  is 
concentrated,  diminished  in  quantity  and  of  high  specific  gravity ;  it 
contains  an  excess  of  urea  and  uric  acid,  and  of  the  sulphates 
and  potassium  salts,  and  a  diminished  amount  of  sodium  chloride. 
In  severe  cases  it  is  often  albuminous. 

EhrlicKs  test—Diazobenzol  reaction. — In  a  large  proportion  of 
cases  this  reaction  is  present,  and  is  not  without  value  as  a  diagnostic 
sign.  Two  solutions  called  A  and  B  are  prepared.  A  consists  of 
a  20  per  cent  solution  of  hydrochloric  acid  saturated  with  sulphanilic 
acid.  B^  of  a  half  per  cent  solution  of  sodium  nitrite.  Immedi- 
ately before  using,  one  part  of  B  is  mixed  with  twenty-five  parts  of 
A^  an  equal  volume  of  urine  is  added  in  a  test-tube  and  strong 
liquor  ammonia  is  dropped  into  the  mixture  or  allowed  to  flow 
down  the  side  of  the  tube.  At  the  junction  a  crimson  ring  forms  ; 
if  the  tube  be  shaken  the  froth  is  coloured  pink  ;  ordinary  urine 
gives  a  more  or  less  deep  orange  colour.  In  applying  the  test  care 
should  be  taken  to  mix  the  solutions  accurately.  The  reaction  is 
seldom  absent  in  typhoid,  even  in  mild  cases,  and  is  valuable  as  a 
negative  test ;  it  is,  however,  occasionally  present  in  other  diseases, 
especially  measles,  pneumonia,  tuberculosis.  Liquid  cultivations  of 
the  typhoid  bacillus  are  said  to  give  it. 

The  urine  in  typhoid  fever  possesses  highly  toxic  properties,  and 
the  typhoid  bacillus  appears  to  be  usually  present  in  it. 

The  blood  in  the  later  stages  of  typhoid  shows  important  changes. 
The  red  cells  and  the  haemoglobin  are  much  diminished ;  the 
leucocytes  are  also  usually  rather  decreased  in  number,  though 
only  slightly ;  these  changes  are  most  marked  in  the  third  and 
fourth  weeks.  Secondary  inflammations  will  cause  an  increase  in 
the  leucocytes.  This  absence  of  leucocytosis  in  typhoid  may  have 
a  diagnostic  value  and  help  to  distinguish  it  from  inflammatory  and 
septicsemic  fevers. 

During  the  second  and  third  weeks  the  symptoms  become  more 
severe,  the  prostration  increases,  there  is  rapid  wasting,  the  tongue 
often  becomes  denuded,  red,  glazed  and  transversely  fissured,  the 
lips  are  dry  and  cracked  ;  often  there  are  sordes  on  the  teeth.  The 
pulse  becomes  dicrotic  from  loss  of  arterial  tone ;  it  may  vary  in 
frequency  from  1 1 2  to  140;  if  persistently  above  120  it  is  an  un- 
favourable sicrn.     The  first  sound  of  the  heart  becomes  altered  in 


"TYPHOID  FEVER  95 

quality,  becoming  short,  more  like  that  of  the  second.  Signs  of 
hypostatic  congestion  of  the  lungs  may  appear,  increased  frequency 
of  breathing,  duskiness  of  the  countenance,  crepitations  over  the 
back  of  the  chest.  Delirium  is  not  infrequent,  at  first  on  waking 
out  of  sleep ;  it  is  usually  of  a  quiet  muttering  character,  sometiaies 
noisy  and  violent.  In  very  severe  cases  the  patient  may  pass  into 
what  is  called  the  "  typhoid  state " ;  there  is  delirium  with  stupor, 
great  prostration,  the  patient  sinking  down  in  the  bed,  and  sub- 
sultus  tendinum  ;  the  urine  and  motions  are  passed  in  the  bed,  or 
the  bladder  may  be  paralysed.  Bed-sores  are  liable  to  form.  The 
patient  may  die  in  a  state  of  coma.  These  severe  symptoms  are 
only  occasionally  present. 

During  the  third  week  the  diarrhoea  usually  becomes  more 
severe ;  there  may  be  six  or  eight  motions  in  the  twenty-four  hours ; 
they  are  often  very  offensive,  alkaline,  and  may  contain  shreddy 
sloughs.  Hsemorrhage,  slight  or  profuse,  is  liable  to  occur,  or 
perforation. 

The  temperature  during  the  third  week  becomes  more  remittent 
in  type,  and  towards  the  end  or  the  beginning  of  the  fourth  begins 
to  fall,  the  morning  temperature  falling  more  rapidly  than  the  even- 
ing. It  is,  however,  by  no  means  unusual  for  the  temperature  to 
keep  up  during  the  first  part  or  the  whole  of  the  fourth  week,  or 
even  longer.  In  favourable  cases,  during  the  fourth  week  defer- 
vescence is  completed,  and  the  temperature  usually  remains  sub- 
normal for  some  time,  but  is  easily  sent  up  by  slight  causes  ;  the 
appetite  returns,  often  before  the  temperature  has  fallen  to  normal, 
and  convalescence  is  established,  though  liable  to  be  interrupted  by 
many  accidents. 

Typhoid  fever  presents  great  variations  in  its  characters  and 
severity,  and  many  forms  are  described,  which,  however,  are  not 
distinguished  by  any  strict  line  of  demarcation.  Considerable 
difference  has  been  noted  in  the  prevalence  of  certain  symptoms  in 
various  epidemics.  In  some  the  symptoms  due  to  the  blood-poison- 
ing are  predominant,  in  others  those  caused  by  the  local  lesions. 

Among  the  more  common  forms  are  :— 

1.  The  acute  form. — This  is  characterised  by  sudden  onset, 
severe  febrile  symptoms  from  the  first,  rigors,  rapid  rise  of  tempera- 
ture, headache,  oppression,  early  delirium,  and  death  may  take 
place,  though  this  is  very  exceptional,  during  the  second  week.  The 
intestinal  lesions  are  not  necessarily  excessive,  and  the  later  stages 
of  the  fever  may  be  less  severe. 

2.  The  abortive  form. — Here  the  earlier  symptoms  may  be 


96  MANUAL   OF   ^lEDICINE 

severe,  but  sometime  between  the  eighth  and  fourteenth  days  a 
rapid  defervescence  takes  place.  Probably  in  these  cases  the 
intestinal  lesions  are  slight  and  have  not  gone  on  to  the  sloughing 
stage. 

3.  The  latent  or  ambulant  form. — Here  the  general  febrile 
disturbance  is  comparatively  slight,  but  the  intestinal  lesions  present 
the  usual  characters.  In  consequence  the  patient  continues  to 
follow  his  usual  avocation  and  walks  about  during  the  whole  or  a 
great  part  of  his  illness,  though  suffering  from  malaise  and  diarrhoea. 
The  neglect  of  proper  precautions  renders  these  cases  very  liable  to 
haemorrhage  and  perforation. 

4.  The  afebrile  form. — Cases  have  been  observed  where  the 
temperature  has  remained  normal  or  subnormal  throughout  the 
attack.  This  has  been  especially  noticed  where  there  had  been 
previously  exposure  to  great  hardships. 

Mild  forms  of  typhoid  are  often  called  febricula,  gastric  fever, 
bilious  fever,  simple  continued  fever,  remittent  fever,  but  these 
terms  should  be  avoided  as  much  as  possible. 

Complications  and  sequelae. — Of  the  complications  of 
typhoid  fever  those  due  to  the  intestinal  lesions  are  the  most 
important,  and  of  these  the  most  serious  are  hccmorrhage  and 
perforation.  They  may  occur  at  two  periods,  most  commonly 
during  the  separation  of  the  sloughs  in  the  latter  half  of  the  third 
or  the  first  half  of  the  fourth  week.  But  they  may  take  place  much 
later,  during  the  stage  of  convalescence,  in  consequence  of  the 
ulcers  not  having  healed.  H(Emor7-hage  occurs  in  about  6  per 
cent  of  the  cases ;  the  amount  may  vary  from  a  slight  oozing  to 
several  pints  of  arterial  blood.  The  blood  may  be  either  dark  or 
bright  red  according  to  the  time  it  has  remained  in  the  bowel  before 
being  evacuated,  and  is  often  clotted.  When  profuse  it  causes  a 
sudden  fall  of  temperature,  pallor,  and  collapse  ;  it  may  be  repeated 
several  times.  A  moderate  haemorrhage  does  not  exercise  any 
injurious  effect  on  the  course  of  the  disease,  but  indicates  deep 
ulceration.  A  profuse  hccmorrhage  may  be  immediately  fatal. 
Hcemorrhage  as  well  as  perforation  may  occur  when  the  bowels 
have  been  previously  constipated. 

Perforation  has  been  estimated  to  occur  in  about  3  per  cent  of 
all  cases.  It  manifests  itself  by  sudden  pain  in  one  part  of  the 
abdomen,  followed  by  signs  of  general  peritonitis,  diffused  abdominal 
pain,  tenderness,  distention,  and  collapse.  The  temperature  often 
falls  and  then  again  rises.  The  pulse  is  very  frequent  and  small,  the 
countenance  pinched  \  there  is  often  hiccough  and  vomiting.     Death 


VOL.  I 


98  MANUAL  OF  MEDICINE 

usually  occurs  from  within  twenty-four  to  forty-eight  hours.  Some- 
times when  the  patient  is  in  a  typhoid  state  these  severe  symptoms 
are  absent,  and  the  chief  indications  are  great  distention  v/ith  in- 
creased prostration  and  some  abdominal  tenderness.  The  abdominal 
distention  is  usually  due  mainly  to  inflation  of  the  intestine,  but 
sometimes  considerable  quantities  of  gas  escape  into  the  peritoneal 
cavity  and  cause  obliteration  of  the  liver  dulness,  an  important 
diagnostic  sign.  Perforation  and  peritonitis  cause  a  great  increase 
in  the  number  of  leucocytes  in  the  blood.  Recovery  may  take 
place  after  symptoms  of  acute  peritonitis  have  occurred  ;  possibly 
in  these  cases  there  has  not  been  actual  perforation,  or  extravasa- 
tion has  been  prevented  or  limited  by  adhesions.  Peritonitis  may 
also  be  caused  by  the  breaking  down  and  rupture  into  the  peri- 
toneal cavity  of  the  infiltrated  mesenteric  glands. 

Ulceration  of  colon. — Occasionally  the  solitary  glands  through- 
out the  colon  and  rectum  are  affected  in  a  similar  manner  to  those 
of  the  ileum,  and  the  whole  of  the  large  bowel  riddled  with  circular 
sloughing  ulcers.  This  condition  is  one  of  great  gravity,  and  is 
manifested  by  the  severity  and  long  persistence  of  the  diarrhoea, 
the  highly  offensive  motions,  which  often  contain  mucus,  and  by 
the  pain  and  sometimes  the  tenesmus  which  accompany  them. 
There  may  be  distinct  tenderness  along  the  course  of  the  colon, 
Haemorrhage  and  perforation  are  liable  to  occur. 

Gastric  disturbance. — Severe  gastric  disturbance  occasionally 
occurs  ;  there  is  flatulent  distention,  sometimes  acute  dilatation  and 
frequent  bilious  vomiting,  so  that  the  patient  can  retain  no  food. 
These  symptoms  are  often  associated  with  severe  headache.  The 
term  bilious  typhoid  has  been  applied  to  this  form. 

Jaundice  occasionally  occurs  in  the  later  stages  of  the  disease 
and  the  case  often  terminates  fatally,  the  motions  remaining  bile- 
stained.  Its  pathology  is  not  certainly  known.  The  liver  is  often 
found  to  be  fatty  with  exudation  of  leucocytes  between  the  lobules. 

Tympanites. — This,  when  great,  is  both  a  distressing  and  dangerous 
symptom.  When  it  occurs  early  it  is  an  indication  of  great  nervous 
depression  ;  later  it  is  usually  associated  with  extensive  ulceration,  or 
it  may  be  a  sign  of  peritonitis.  The  distention  may  affect  both  the 
large  and  small  intestine.  It  tends  to  embarrass  the  patient's  respira- 
tion, and  increases  the  risk  of  perforation  by  stretching  the  intestinal 
wall. 

Respiratory  complications. — Some  degree  of  bronchitis  is  usually 
present.  In  severe  cases,  in  the  later  stages  there  is  often  hypostatic 
congestion  of  the  lungs  due  to  weakness  of  the  heart,  and  favoured 


TYPHOID   FEVER  99 

by  the  dorsal  decubitus  of  the  patient.  It  is  manifested  by  frequent 
shallow  breathing  and  some  duskiness  of  countenance  ;  the  physical 
signs  are  some  degree  of  impairment  of  resonance  over  the  back, 
with  rather  fine  crepitant  rales. 

Lobar  pneumonia  is  an  occasional  complication.  It  is  most 
common  in  the  third  or  fourth  week  of  the  disease,  and  is  due  to 
invasion  by  the  pneumococcus,  and  not  to  the  direct  action  of  the 
typhoid  bacillus.  Occasionally  it  occurs  at  the  outset,  and  is 
possibly  due  to  a  primary  infection  of  the  lung,  the  intestinal 
symptoms  developing  later.  Cases  of  pneumonia  have  been  met 
with  during  an  epidemic  in  persons  who  have  been  exposed  to  the 
contagion  without  any  other  symptoms  of  typhoid  developing. 
When  it  occurs  late  in  the  disease  many  of  the  usual  symptoms 
may  be  absent ;  there  is  often  little  cough  and  no  expectoration, 
but  the  breathing  is  quickened,  the  countenance  dusky,  the  alae  nasi 
often  dilate,  and  there  may  be  pain  in  the  side.  Though  a  very 
serious  complication,  it  is  not  necessarily  fatal. 

Embolic  and  pysemic  processes  in  the  lungs  are  liable  to  occur, 
and  may  give  rise  to  abscess,  empyema,  or  pneumothorax. 

Ulceration  of  the  larynx.,  originating  in  the  lymph  follicles,  is 
not  infrequent ;  often  it  gives  rise  to  few  symptoms,  in  other  cases 
there  is  huskiness  or  stridor  of  the  voice  and  cough,  pain  in 
swallowing,  and  tenderness,  on  pressure,  over  the  larynx.  Generally 
the  ulcers  heal  without  causing  any  serious  mischief  They  may, 
however,  extend  deeply,  and  cause  necrosis  of  the  cartilages,  oedema, 
and  stenosis  of  the  glottis,  and  necessitate  tracheotomy  ;  sometimes 
they  cause  profuse  hsemorrhage. 

Cardiac  complications. — Endo-  or  pericarditis  are  rarely  met  with, 
but  in  severe  cases  the  muscular  wall  is  softened  and  the  cavities 
dilated.  This  condition  is  indicated  by  a  short,  rather  sharp,  first 
sound,  feeble  impulse,  and  perhaps  slight  extension  of  the  area  of 
cardiac  dulness.  Sometimes  there  is  a  systolic  apex  murmur  due  to 
the  dilatation  and  to  the  weakening  of  the  musculi  papillares.  When 
recovery  takes  place,  the  heart  usually  returns  to  its  normal  condition. 
Sometimes  sudden  death  occurs  during  convalescence,  probably  due 
to  this  condition  of  the  heart.  Thrombosis  of  the  cavities  of  the 
heart  or  pulmonary  artery  may  occur  from  stagnation  of  the  circu- 
lation. 

Thrombosis  of  the  veins.,  chiefly  the  saphena,  the  femoral,  and  the 
iliac  veins,  often  occurs  during  convalescence.  It  may  begin  in  the 
intramuscular  veins  as  the  result  of  the  myositis  typhosa,  and  extend 
to  the  larger  veins.      Generally,  in  a  variable  time,  from  three  to  six 


lod  MANUAL  OF  MEDICINE 

weeks,  the  thrombus  gets  absorbed,  and  the  calibre  of  the  vein  is 
restored.  Sometimes  the  obstruction  remains  permanent ;  occasion- 
ally it  gives  rise  to  pulmonary  embolism.  The  affection  is  marked 
by  swelling  of  the  leg,  pain,  and  tenderness  along  the  course  of  the 
affected  vein,  which  can  often  be  felt  as  a  hard  cord. 

Renal  complications. — Albumen  is  often  present  in  the  urine  in 
severe  cases,  but  disappears  as  defervescence  takes  place.  Occa- 
sionally acute  tubular  nephritis  occurs,  characterised  by  scanty, 
bloody,  highly  albuminous  urine,  containing  epithelial  casts.  There 
may  be  dropsy  and  ursemic  symptoms.  The  term  nephrotyphoid 
has  been  given  to  these  cases. 

Nervous  complications. — Various  disturbances  of  the  nervous 
system  may  occur  during  and  after  the  attack.  The  headache, 
delirium,  subsultus,  and  floccitatio  or  picking  at  the  bedclothes,  of 
severe  cases  are  not  accompanied  by  any  appreciable  lesions  of  the 
nerve  centres,  and  are  probably  toxic  in  their  nature.  Sometimes 
spasmodic  and  convulsive  affections,  as  retraction  of  the  head, 
rigidity  of  the  trunk  or  limbs,  strabismus,  trismus,  take  place, 
without  any  lesion  being  detected. 

Meningitis  is  a  rare  complication,  and  is  usually  of  septic  origin  ; 
but  in  some  cases  the  typhoid  bacillus  has  been  found  in  the  exuda- 
tion. Thrombosis  and  embolism  of  the  cerebral  arteries  may  occur, 
and  cause  hemiplegia  and  aphasia,  which  are  usually  recovered  from. 

Peripheral  neuritis  affecting  the  nerves  of  the  extremities  some- 
times manifests  itself  during  convalescence.  Pain,  tenderness,  loss 
of  power,  numbness,  and  tingling,  are  observed.  A  common  seat  is 
the  ulnar  nerve,  causing  numbness,  tingling,  and  loss  of  sensation  in 
the  little  and  ring  fingers ;  this  is  probably  due  to  pressure  on  the 
nerve  behind  the  condyle  of  the  humerus,  from  the  arm  being  con- 
stantly kept  in  one  position  owing  to  the  apathy  of  the  patient. 
Extreme  tenderness  of  the  toes  may  occur,  lasting  a  week  or  ten  days, 
probably  due  to  peripheral  neuritis.  The  symptoms  in  some  cases 
suggest  the  possible  implication  of  the  vagus. 

Another  extremely  painful  affection  during  convalescence,  which 
is  probably  of  a  neuralgic  nature,  has  been  termed  the  typhoid  spine. 
There  is  extreme  pain  over  the  lower  part  of  the  back  and  the  sacral 
region,  especially  on  movement ;  moving  the  legs  also  causes  great 
pain.  There  is  no  paralysis,  or  alteration  of  the  electrical  reactions. 
The  condition  may  last  for  several  weeks. 

Occasionally  serious  lesions  of  the  spinal  cord  have  followed 
typhoid,  as  poliomyelitis,  and  disseminated  sclerosis. 

Melancholia,  dementia,  and  sometimes  mania,  are  liable  to  follow 


Temperature  Curve  in  a  Case  of  Typhoid  Fever— Two  Relapses— Recovery. 


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TYPHOID   FEVER  loi 

typhoid.     They  are  generally  only  temporary,  but  may  necessitate 
putting  the  patient  under  restraint. 

Organs  of  special  sense :  a  temporary  deafness  is  often  present 
during  the  attack ;  occasionally  a  suppurative  otitis  media  occurs. 
Double  optic  neuritis  may  be  present,  without  there  being  any 
intracranial  disease. 

Recurrent  rigors  are  sometimes  observed  during  the  attack, 
without  any  suppuration  following.  Occasionally,  however,  pyaemia 
occurs.  More  frequently  external  suppurations  manifest  themselves, 
often  during  convalescence ;  among  these  is  a  suppurative  parotitis, 
the  gland  probably  getting  infected  by  germs  entering  from  the  mouth 
through  the  duct. 

Sometimes  there  is  a  superficial  suppurative  osteitis  affecting 
especially  the  ribs,  femur,  and  tibia.  The  typhoid  bacillus  has  been 
discovered  in  the  pus  of  these  abscesses.  Sometimes  the  affection 
has  a  rheumatic  character ;  there  are  aching  pains,  especially  at 
night,  swelling  of  the  epiphyses  with  irregular  fever,  and  the  affection 
may  last  for  weeks  without  suppuration  taking  place. 

Relapses  are  very  common ;  their  frequency  has  been  estimated 
at  5  to  I  o  per  cent.  Most  commonly  the  relapse  takes  place  within 
fourteen  days  after  defervescence,  but  the  interval  has  been  known 
to  be  as  long  as  ten  weeks.  In  the  relapse  all  the  symptoms  recur, 
and  the  rose  spots  come  out  again,  and  fresh  infiltration  and  ulcera- . 
tion  of  the  intestinal  glands  takes  place.  Most  commonly,  but  by 
no  means  always,  the  relapse  runs  a  shorter  course  than  the  primary 
attack.  The  fever  attains  its  maximum  between  the  fourth  and  sixth 
days,  and  defervescence  begins  before  the  end  of  the  second  week ; 
but  the  attack  may  last  the  usual  time.  A  second,  and  even  a  third, 
relapse  may  take  place.  Relapses  are  often  attributed  to  errors  of 
diet  during  convalescence,  but  they  frequently  occur  when  all  pre- 
cautions have  been  strictly  observed.  Besides  these  relapses  after 
defervescence,  intercurrent  relapses,  or  recrudescences,  may  take 
place  before  the  temperature  has  become  normal ;  they  are  indicated 
by  an  exacerbation  of  the  febrile  symptoms  and  the  appearance  of  a 
fresh  crop  of  rose  spots.  In  this  way  an  attack  of  typhoid  may  be 
indefinitely  prolonged. 

Desquamation  of  the  cuticle  sometimes  takes  place  after  typhoid. 
Occasionally  the  hair  falls  out ;  the  nails  may  show  a  transverse 
groove,  indicating  cessation  of  growth  during  the  attack. 

A  condition  of  marasmus  may  follow,  due,  possibly,  to  atrophy 
of  the  mesenteric  glands. 

Pregnant    women    very    commonly,  but    not    always,   miscarry. 


I02  MANUAL   OF   MEDICINE 

The  child,  if  near  the  full  time,  may  be  born  alive  and  healthy ; 
but  it  has  been  found  infected  with  typhoid  bacilli  in  the  blood 
and  spleen. 

Diagnosis. — The  chief  points  to  be  noted  in  the  diagnosis  of 
typhoid  fever  are :  the  rose  spots,  the  diarrhoea,  the  enlarged  spleen, 
the  tumid  abdomen,  the  characters  of  the  tongue,  and  the  duration 
and  course  of  the  fever.  In  temperate  countries,  a  fever  which  lasts 
a  week  without  the  appearance  of  any  characteristic  rash,  or  any  local 
inflammation,  is  almost  always  typhoid. 

To  these  points  must  be  added  the  diazobenzol  reaction  of  the 
urine,  and  Widal's  serum  test.  This  last  depends  on  the  fact  that  the 
blood  serum  of  persons  suffering  from  typhoid,  or  who  have  been 
rendered  immune  by  a  previous  attack,  impairs  the  vitality  of  the 
typhoid  bacilli,  and  causes  them,  when  cultivated  in  a  liquid 
medium,  to  clump  together  and  become  motionless.  In  applying 
Widal's  test  the  points  to  be  especially  observed  are — first,  to  use 
only  a  fresh  bouillon  culture,  as  the  typhoid  bacillus  rapidly  loses  its 
potency.  Secondly,  to  dilute  the  serum  or  adjust  its  proportion  to 
the  culture,  as  the  clumping  action  may  be  produced  by  healthy 
serum  if  too  concentrated ;  the  proportion  must  not  exceed  one 
drop  of  serum  to  ten  drops  of  the  culture ;  in  the  second  week  of 
typhoid  I  to  loo  is  often  sufficient.  Thirdly,  to  note  the  time 
required  to  effect  the  clumping ;  this  should  not  exceed  half  an 
hour,  often  a  few  seconds  are  sufficient ;  healthy  serum  may  produce 
the  reaction  in  the  course  of  a  few  hours  (see  p.  33). 

The  most  convenient  method  of  procedure  is  as  follows  : — The 
lobe  of  the  ear  should  be  punctured  and  a  little  blood  squeezed  out 
into  a  small  tube,  or  sucked  out  by  means  of  a  capillary  pipette  and 
expelled  into  the  tube.  It  should  be  allowed  to  coagulate,  and  by 
means  of  a  platinum  loop  a  drop  of  the  serum  added  to  lo^  or, 
better,  20  or  even  30  drops  of  the  culture  and  examined  at  once 
under  the  microscope  between  a  cover-glass  and  slide.  The  pro- 
portion of  I  to  10  is  open  to  many  fallacies.  The  blood  as  drawn 
may  be  used,  but  the  corpuscles  are  apt  to  obscure  the  microscopical 
appearances.  No  antiseptic  precautions  are  necessary,  as  there  is 
not  time  for  other  organisms  to  grow.  Dried  blood  or  dried  serum 
can  be  employed  after  dissolving  in  water,  but  it  is  difficult  to 
estimate  the  degree  of  dilution.  If  the  blood  has  to  be  sent  away 
for  examination  it  should  be  withdrawn  with  antiseptic  precautions 
and  sealed  up  in  a  capillary  tube  furnished  with  a  bulb.  The 
reaction  may  usually  be  obtained  by  the  seventh  day,  and  has  been 
found  as  early  as  the  fifth ;  but  its  appearance  may  be  delayed  till 


TYPHOID   FEVER  103 

a  much  later  period,  even  as  late  as  the  twentieth  day.  It  may 
continue  for  a  few  days  after  convalescence  to  many  years,  or 
possibly  the  remainder  of  the  patient's  life.  It  may  be  temporarily 
absent  and  appear  again,  so  that  if  a  negative  result  is  obtained  it  is 
necessary  to  repeat  the  test  several  times.  On  the  whole,  it  may  be 
said  that  the  presence  of  the  reaction  in  a  person  who  has  not  had 
a  previous  attack  is  an  almost  certain  indication  of  the  disease ;  but 
its  absence  on  any  given  occasion  does  not  necessarily  exclude  it. 

In  certain  cases,  exhibiting  all  the  clinical  features  of  typhoid 
fever,  when  the  Widal  reaction  has  been  wanting,  the  B.  typhosus 
has  not  been  found,  but  another  organism  differing  both  in  morpho- 
logical and  cultural  characters  from  the  typhoid  microbe  and  from 
B.  coli. 

The  diseases  with  which  typhoid  is  most  likely  to  be  confounded 
are,  first,  acute  tuberculous  affectio?is,  especially  meningitis,  general 
miliary  tuberculosis,  and  tuberculous  affections  of  the  abdominal 
viscera. 

In  tuberculous  meningitis  vomiting  is  a  more  prominent  symptom. 
The  abdomen  is  usually  retracted  instead  of  being  tumid  ;  the  bowels 
are  commonly  constipated ;  the  tongue  is  not  red ;  the  spleen  is  not 
enlarged ;  the  pulse  is  often  infrequent ;  the  temperature  is  more 
irregular  ;  the  tache  cerebrale  better  marked.  The  knee  jerk  is  often 
absent,  whereas  in  typhoid  it  is  often  exaggerated.  Later  on  there 
may  be  the  hydrocephalic  cry,  spasm,  or  paralysis  of  the  cerebral 
nerves ;  but  it  must  be  remembered  that  in  typhoid  there  may  be 
inequality  of  the  pupils,  strabismus,  twitching  of  the  muscles,  double 
optic  neuritis.  "  Stocker's  symptom  "  is  of  some  value  ;  in  typhoid, 
if  the  bedclothes  be  pulled  down  the  child  is  indifferent,  but  in 
tuberculous  meningitis  he  resists  and  immediately  draws  them  up 
again.  In  typhoid  the  decubitus  is  usually  dorsal,  in  meningitis 
lateral.  The  presence  of  tubercles  in  the  choroid  would  be  a 
valuable  diagnostic  sign. 

In  acute  miliary  tuberculosis  the  pulmonary  symptoms  are  usually 
much  more  severe  than  in  the  early  stage  of  typhoid.  There  is 
usually  great  rapidity  of  the  breathing  ;  the  alse  nasi  dilate  ;  the  face 
is  somewhat  cyanosed  ;  fine  crepitant  rales  are  audible  over  the  chest ; 
the  temperature  is  much  more  irregular,  and  may  be  of  the  inverse 
type,  i.e.  higher  in  the  morning  than  in  the  evening.  •  If  there  is  also 
tuberculosis  of  the  intestine,  there  may  be  diarrhoea,  and  a  swollen 
abdomen. 

Tuberculous  peritonitis  may  resemble  typhoid,  but  is  usually 
much  more  chronic,  and  often  there  are  signs  of  peritoneal  effusion. 


I04  MANUAL  OF   MEDICINE 

Pneumonia  of  the  asthenic  type  may  closely  resemble  typhoid,  but 
may  be  distinguished  by  the  physical  signs.  When  it  occurs  as  a 
complication  of  typhoid,  other  symptoms  must  be  looked  to — the 
rose  spots,  the  enlarged  spleen,  the  diarrhoea,  etc.  Most  commonly 
pneumonia  occurs  in  the  later  stages  of  typhoid,  so  that  the  duration 
of  the  attack  will  have  been  longer  than  is  usual  in  primary 
pneumonia. 

The  fever  which  accompanies  appendicitis  and  perityphlitis  often 
resembles  typhoid,  but  the  local  pain,  tenderness,  and  swelling  will 
serve  to  distinguish  them. 

Typhoid  fever  is  very  liable  to  be  mistaken  at  the  onset  for 
influenza.  The  invasion  of  the  latter  is  usually  more  sudden,  and 
the  early  symptoms  more  severe.  The  temperature  reaches  its  maxi- 
mum much  sooner.  The  pains  in  the  head  and  limbs  are  more 
intense,  and  of  a  more  neuralgic  character ;  and  unless  some  local 
complication  interferes,  defervescence  takes  place  in  the  course  of 
a  few  days.  If  the  fever  persists  without  any  local  cause,  the  case 
is  probably  typhoid. 

Ulcerative  endocarditis  and pycemla  may  closely  resemble  typhoid, 
and  the  former  may  even  cause  intestinal  haemorrhage  from  embolism. 
The  greater  irregularity  of  the  temperature,  the  signs  of  embolism,  as 
purpuric  spots  and  blotches  on  the  skin,  hgematuria,  and  the  cardiac 
signs,  are  the  chief  points  of  distinction. 

In  children  acute  gastric  and  Intestinal  catarrh  may  simulate  the 
milder  forms  of  typhoid ;  but  the  febrile  disturbance  is  of  shorter 
duration,  the  spleen  is  not  enlarged,  and  there  are  no  spots.  A  suit- 
able purge  will  often  remove  the  symptoms. 

In  tropical  climates,  in  malarial  districts,  there  may  be  great 
difficulty  in  distinguishing  malarial  reinlttents  from  typhoid,  and  no 
doubt  both  infections  may  be  present  together. 

For  the  diagnosis  from  typhus,  see  the  latter  disease. 

Prognosis. — The  rate  of  mortality  of  typhoid  fever  varies  so 
much  in  different  epidemics  and  under  different  modes  of  treat- 
ment, that  it  is  impossible  to  give  any  average  generally  applicable. 
In  the  general  hospitals  of  London  it  is  about  i6  per  cent;  in  the 
Fever  Hospitals  of  the  Metropolitan  Asylums  Board  somewhat 
higher ;  in  private  practice  probably  less,  and  often  much  less  in 
extensive  epidemics. 

It  is  claimed  that  systematic  cold  bathing  will  reduce  the 
hospital  mortality  to  less  than  half  that  given  above.  An  equally 
great  reduction  is  claimed  by  the  advocates  of  the  antiseptic  treat- 
ment. 


TYPHOID   FEVER  105 

Age. — The  influence  of  age  in  the  rate  of  mortahty  of  typhoid 
is  much  less  than  in  typhus,  but  the  mortahty  in  childiiood  is  less 
than  in  adult  life,  and  after  thirty -five  is  decidedly  higher  than 
below  that  age.  Sex. — The  mortality  of  females  is  slightly  higher 
than  that  of  males.  Bodily  habit. — Great  obesity  and  also  great 
muscular  development  are  unfavourable. 

Antecedent  and  general  conditiotis. — Intemperate  habits,  too  high 
living,  organic  disease,  as  of  the  heart  or  kidneys,  delay  in  the  com- 
mencement of  treatment,  increase  the  rate  of  mortality.  It  has  often 
been  observed  that  among  the  Irish,  who  are  comparatively  ill-fed 
and  live  largely  on  potatoes,  the  rate  of  mortality  is  very  low. 

Unfavourable  symptoms. — The  more  important  among  these  are 
indications  of  severe  intestinal  lesions,  as  urgent  diarrhoea,  haemor- 
rhage, abdominal  pain,  great  tympanites,  disturbance  of  the  nervous 
system,  as  muttering  delirium,  tendency  to  stupor,  muscular  twitch- 
ings,  a  pulse  persistently  above  120,  indications  of  heart  failure, 
hypostatic  congestion  of  the  lungs,  a  persistent  high  temperature, 
especially  if  accompanied  by  disturbance  of  the  nervous  system. 
Mere  temporary  rises  of  temperature  are  of  comparatively  little 
moment. 

Prophylaxis  of  typhoid. — This  is  mainly  a  question  of  public 
hygiene  and  sanitation,  to  ensure  that  the  water  supply  is  not  con- 
taminated by  sewage ;  that  the  sanitary  arrangements  are  in  good  order 
and  do  not  allow  the  emanations  from  drains  and  soil  pipes  to  escape 
into  houses  and  foul  the  cisterns  ;  to  prevent  the  contamination  of 
milk  and  shell  fish,  and  other  articles  of  food.  If  there  is  any  reason 
to  suspect  contamination,  milk  and  water  should  be  boiled. 

To  prevent  the  spread  of  contagion  from  individual  cases,  the 
following  precautions  should  be  followed  : — The  room  should  be 
kept  well  ventilated,  and  abundant  cubic  space  should  be  allowed, 
1500  cubic  feet  if  possible.  The  strictest  cleanliness  should  be 
observed.  After  handling  the  patient,  the  attendants  should  dip 
their  hands  in  an  antiseptic  solution,  as  hydrarg.  perchlor.  i  to  1000, 
a  basin  of  which  should  be  placed  on  a  table  near  the  bed.  If  the 
hands  get  soiled,  they  should  be  washed  with  carbolic  acid  soap. 
After  every  motion  the  parts  should  be  sponged  or  wiped  with  some 
antiseptic  lotion,  as  weak  condy  or  carbolic  acid.  Soiled  linen  should 
be  steeped  in  some  disinfecting  solution  before  being  sent  to  the 
laundry. 

The  disposal  of  the  excreta  is  a  matter  of  much  importance,  as 
it  is  by  them  that  the  disease  is  chiefly  spread.  The  safest  way  of 
dealing  with  them — but  this  is  seldom  practicable — is  to  burn  them  ; 


io6  MANUAL  OF  MEDICINE 

they  may  be  mixed  with  sawdust,  oil  of  turpentine  or  naphtha  poured 
over  them,  and  set  on  fire.  Under  ordinary  circumstances  they 
should  be  disinfected  before  being  thrown  down  drains  or  buried,  by 
being  mixed  with  crude  carbolic  acid,  or  perchloride  of  mercury,  or 
some  other  disinfectant,  and  allowed  to  stand  for  an  hour  or  two. 
The  urine,  also,  should  be  disinfected.  Earth  closets  are  not  suit- 
able for  typhoid  evacuations. 

The  nurses  should  not  eat  or  drink  in  the  sick-room,  and  never 
without  washing  their  hands. 

Protective  inoculation  and  semm  treatment. — Inoculation  of  living 
or  sterilised  cultures  of  the  typhoid  bacillus  renders  animals  immune 
against  the  action  of  the  typhoid  bacillus  and  its  toxines,  and  the 
serum  of  animals  thus  rendered  immune  confers  immunity  when 
injected  subcutaneously.  According  to  Pfeiffer  the  action  of  such 
serum  is  rather  bactericidal  than  antitoxic,  and  this  militates  against 
its  curative  powers. 

Sterilised  cultures  may  be  employed  as  a  protective  vaccine,  and 
the  serum  of  immunised  animals  as  a  curative  agent.  The  subject 
is  still  in  the  experimental  stage,  but  the  evidence  for  the  preventive 
action  of  the  vaccine  is  much,  stronger  than  that  for  the  curative 
action  of  the  serum,  which  latter  must  be  regarded  as  still  unproved. 
The  inoculation  of  sterilised  cultures  appears  to  be  free  from  risk, 
and  deserves  trial  during  epidemics  and  in  the  case  of  persons  like 
nurses  who  are  especially  exposed  to  infection. 

Treatment. — As  soon  as  the  diagnosis  of  typhoid  becomes 
probable,  the  patient  should  be  strictly  confined  to  bed,  and  should 
pass  his  evacuations  in  a  bed  pan  and  urine  glass.  The  room  should 
be  kept  cool ;  the  temperature  should,  if  possible,  not  exceed  60^. 
The  bed  should  be  narrow,  with  an  elastic  mattress,  and  a  water- 
proof cloth  under  the  sheet.  He  should  be  lightly  covered  wiih  a 
sheet  and  thin  coverlet,  with  a  blanket  over  his  feet.  The  diet 
should  be  liquid,  administered  at  regular  intervals  every  four  hours, 
or  oftener  if  there  is  much  prostration,  and  he  should  have 
abundance  of  drink  given  him  to  assist  elimination  through  the 
kidneys.  It  should  be  remembered  that  the  digestive  and  assimilat- 
ing powers  are  much  impaired ;  it  is  not  therefore  advisable  to  over- 
task them  by  an  excess  of  food.  The  chief  articles  of  food  employed 
are  milk,  two  to  three  pints  of  which  may  be  given  in  twenty-four 
hours,  together  with  animal  broths  and  solutions  of  meat ;  ordinarily 
about  a  pint  of  beef  tea  may  be  given  ;  beaten-up  eggs,  or  egg 
albumen  mixed  with  water,  thin  gruel  and  arrowroot  may  be  ad- 
ministered.    Plain  water,  barley  water,  acidulated  drinks,  weak  tea, 


TYPHOID   FEVER  107 

■which  last  is  an  excellent  diuretic,  may  be  allowed  in  small  quantities 
at  a  time,  according  to  the  patient's  liking.  It  is  also  advisable  to 
give  an  ounce  of  glucose  daily  to  supply  the  liver  with  glycogen, 
which  under  ordinary  diets  disappears  from  the  liver  cells  in  septic 
fevers,  but  which  may  be  restored  by  administering  glucose,  and  so 
the  wasting  may  be  diminished.  It  may  be  used  to  sweeten  milk, 
tea,  arrowroot,  acid  drinks. 

When  the  patient  is  fed  largely  on  milk  the  motions  should  be 
.carefully  inspected  to  see  that  they  do  not  contain  curds ;  if  this  is 
the  case  the  amount  of  milk  must  be  diminished,  or  it  must  be  given 
•diluted  with  barley  water  or  lime  water,  or  it  may  be  peptonised,  or 
humanised  milk  substituted. 

In  severe  cases,  when  signs  of  prostration  show  themselves, — a 
dicrotic  pulse,  weak  action  of  the  heart,  congestion  of  the  lungs, 
delirium,  tremors, — alcoholic  stimulants  should  be  freely  administered, 
and  it  is  better  to  anticipate  rather  than  to  defer  their  use.  Brandy 
is  perhaps  the  one  most  to  be  relied  on,  but  the  patient's  pre- 
dilections, if  he  has  any,  may  be  deferred  to.  The  amount  must 
depend  on  the  age  and  condition  and  previous  habits  of  the  patient, 
and  the  effect  produced.  Young  subjects  require  less  than  older 
persons.  From  three  to  eight  ounces  or  more  of  brandy  are  often 
required  in  twenty-four  hours. 

To  combat  the  disease  three  chief  methods  are  employed,  which 
may  be  termed  the  antipyretic,  the  antiseptic  and  the  eliminative. 
The  first  consists  in  keeping  the  temperature  through  the  whole 
course  of  the  disease  below  a  moderate  fever  height.  The  most 
effectual  method  of  doing  this,  and  the  one  which  gives  the  best 
results,  is  by  bathing  the  patient  in  tepid  water.  Whenever  the 
temperature  rises  above  102.5''  Fahr.,  he  should  be  lifted  into  a  bath 
of  a  temperature  of  80°  Fahr.  and  kept  immersed  for  about  fifteen 
minutes,  or  till  shivering  sets  in.  In  some  cases  baths  of  a  lower 
temperature  may  be  employed  or  the  temperature  of  the  water  cooled 
by  ice  after  the  patient's  immersion.  The  temperature  will  continue 
to  fall  for  some  time  after  removal  from  the  bath.  When  taken  out 
the  patient  should  be  laid  on  a  blanket,  wiped  dry,  and  lightly 
covered  ;  a  little  alcohol  should  be  given  before  the  bath.  A^'herever 
this  mode  of  treatment  has  been  systematically  carried  out  it  has 
always  been  found  to  effect  a  great  decrease  in  the  rate  of  mortality. 
The  good  effects  produced  are  by  no  means  confined  to  the  lower- 
ing of  the  temperature.  The  pulse  is  reduced  in  frequency,  its  tone 
is  improved,  the  respirations  are  deepened,  headache,  delirium, 
insomnia,  subsultus,  are  prevented  or  relieved,  the  amount  of  the 


io8  MANUAL   OF   MEDICINE 

urine  is  increased,  and  its  toxicity  during  the  fever  period  is  greatly 
intensified,  while  in  the  stage  of  convalescence  it  is  diminished, 
showing  that  this  mode  of  treatment  is  powerfully  eliminative,  and  it 
is  probable  that  this  is  one  of  its  chief  advantages.  Haemorrhage 
and  peritonitis,  but  not  congestion  of  the  lungs,  contra-indicate 
bathing. 

Where  bathing  cannot  be  employed  recourse  may  be  had  to  cold 
sponging ;  sometimes  where  there  is  much  collapse  and  cold  sponging 
is  greatly  objected  to  by  the  patient,  sponging  with  very  hot  water, 
1 1  o°  Fahr.,  and  afterwards  leaving  the  patient  lightly  covered,  will 
bring  down  the  temperature.  Packing  in  a  wet  sheet  or  applying 
iced  compresses  to  the  chest  and  abdomen  are  also  useful  means. 
Another  method  is  to  put  a  cradle,  merely  covered  by  a  sheet,  over 
the  patient,  inside  which  may  be  placed  trays  of  ice,  and  so  keep- 
ing him  in  a  bath  of  cool  air.  Many  drugs  have  the  effect  of 
reducing  temperature  ;  the  most  important  are  quinine  in  large  doses, 
antipyrine,  acetanilide,  phenacetine,  but  their  use  for  this  purpose, 
except  an  occasional  dose,  which  sometimes  produces  good  effects, 
is  not  to  be  recommended  owing  to  their  depressing  action  on  the 
heart.  Quinine  in  smaller  doses  may  be  given  with  advantage  in 
the  later  stages  of  the  disease. 

The  antiseptic  treatment  consists  in  administering  remedies  to 
destroy  or  render  inert  the  typhoid  and  septic  microbes  in  the 
intestinal  canal.  A  large  number  of  such  remedies  have  been  em- 
ployed, among  them  calomel,  perchloride  of  mercury,  iodine,  carbolic 
acid  and  the  sulpho-carbolates,  salol,  /3-naphthol,  guaiacol,  turpentine, 
and  many  others.  By  their  use  the  putrefactive  and  fermentative 
changes  in  the  intestinal  canal  may  be  arrested  and  the  faeces 
deprived  of  their  offensive  smell,  but  no  effect  is  produced  in 
destroying  either  the  saprophytic  germs  which  are  free  in  the 
intestine,  or  the  typhoid  bacilli  which  are  lodged  in  the  glands 
and  spleen  ;  these  remedies  have  been  largely  used  in  America,  and 
very  successful  results  are  claimed  for  them. 

The  practice  has  been  recently  revived  of  treating  typhoid  by 
purgatives  with  the  object  of  eliminating  the  toxines  and  getting  rid 
of  the  bacillus.  The  typhoid  bacilli  are,  however,  mainly  embedded 
in  the  tissues  and  glands  and  are  therefore  unaffected  by  purgatives, 
and  there  are  obvious  dangers  in  stimulating  an  ulcerated  bowel  to 
active  peristalsis.  Many  physicians,  however,  consider  a  calomel 
purge  beneficial  in  the  early  stage  of  the  disease. 

Apart  from  attempts  to  control  the  general  course  of  the  disease, 
the  special  symptoms  require  treatment. 


TYPHOID   FEVER  109 

With  regard  to  the  bowels,  it  is  safer  not  to  give  purgatives  by 
the  mouth  after  the  first  week  or  ten  days.  If  there  is  constipation, 
enemata  should  be  employed,  as  it  is  evidently  inadvisable  to  leave  the 
bowels  full  of  putrefactive  and  fermenting  faeces.  Commonly  there 
is  diarrhoea  ;  if  the  motions  do  not  exceed  three  or  four  in  the  twenty- 
four  hours  no  special  treatment  is  required.  If  they  much  exceed 
this  opium  may  be  administered  either  by  the  mouth  or  as  an 
enema,  and  care  should  be  taken  to  adapt  the  diet ;  sometimes  milk 
disagrees,  sometimes  beef  tea. 

If  a  profuse  hsemorrhage  occur  the  patient  should  be  kept 
perfectly  still ;  he  should  pass  his  motions  into  a  draw  sheet ;  the  ad- 
ministration of  food  should  be  suspended  for  some  hours.  Opium 
should  be  given  to  arrest  peristalsis,  and  in  addition  styptics  may  be 
had  recourse  to,  though  their  efficacy  is  somewhat  doubtful.  The 
best  are  perhaps  turpentine,  acetate  of  lead  and  ergot ;  the  last  may 
be  administered  subcutaneously.  If  the  patient  appears  to  be  in  danger 
of  sinking,  transfusion  of  a  saline  solution  into  the  veins  should 
be  resorted  to. 

Perforation  is  almost  always  fatal ;  if  diagnosed  early  and  the 
patient's  general  condition  is  still  fairly  good,  the  best  chance  is 
to  perform  laparotomy,  wash  out  the  peritoneum  and  close  the 
perforation.  A  sufficient  amount  of  success  has  now  been  obtained 
as  to  justify  the  operation  in  all  favourable  cases,  and  it  should 
always  be  performed  when  perforation  occurs  during  convalescence. 
If  the  operation  is  not  deemed  advisable  opium  should  be  ad- 
ministered in  full  doses. 

For  the  treatment  of  meteorismus  stimulants  may  be  administered 
when  there  are  signs  of  nervous  prostration,  together  with  strychnia  ; 
cold  compresses  may  be  applied  to  the  abdomen,  an  enema  of  rue 
or  ol.  terebinth  administered.  Sometimes  relief  may  be  obtained 
by  introducing  a  rectal  tube. 

Ulceration  of  the  large  intestine,  which  will  cause  the  diarrhoea 
to  persist  after  defervescence,  requires  careful  regulation  of  the  diet ; 
acetate  of  lead  may  be  given  combined  with  opium ;  large  doses  of 
subnitrate  of  bismuth  are  sometimes  useful. 

Hypostatic  congestion  of  the  lungs  and  pneumonia  require 
alcoholic  stimulants,  together  with  ammonia  and  ether ;  mustard  and 
linseed  meal  may  be  applied,  but  the  chest  should  not  be  blistered. 

Heart  failure  may  be  treated  by  ether  and  strychnia  administered 
hypodermically.      Digitalis  and  ammonia  may  be  given. 

Nervous  symptoms,  as  sleeplessness,  delirium,  headache,  are 
often  relieved  by  bringing  down  the  temperature  by  bathing,  sponging, 


110  MANUAL  OF  MEDICINE 

the  application  of  cold  to  the  head.  For  sleeplessness,  which  should 
never  be  allowed  to  persist,  the  safest  drug  is  opium. 

Thrombosis  of  the  veins  of  the  lower  extremity  should  be  treated 
by  keeping  the  leg  still  by  means  of  sandbags  laid  on  each  side,  and 
extract  of  belladonna  may  be  applied  along  the  course  of  the  affected 
vein. 

Great  care  is  required  during  convalescence ;  solid  food  should 
be  resumed  very  gradually,  and  not  until  the  temperature  has  been 
normal  in  the  evening  for  several  days  ;  if  there  have  been  marked 
signs  of  ulceration,  for  at  least  a  week.  At  first  a  rusk  or  a  sponge 
cake  may  be  allowed,  and  a  piece  of  chocolate,  which  children 
especially  eat  with  relish  ;  then  a  lightly  poached  egg  and  a  thin  piece 
of  bread  and  butter  ;  next  a  little  boiled  fish  ;  later  tender  meat  and 
potatoes  mashed  or  made  into  a  puree.  The  temperature,  which  is 
usually  at  first  subnormal,  remains  for  a  considerable  time  in  a  very 
unstable  state,  the  resumption  of  solid  food,  constipation,  any  mental 
excitement  will  often  cause  a  temporary  febrile  exacerbation  ;  the 
heart  too  remains  weak,  and  any  strain  or  over-exertion  may  cause 
a  fatal  syncope  or  lead  to  dilatation.  After  an  attack  of  typhoid  the 
patient  should  always  have  a  period  of  rest  at  a  health  resort  or 
convalescent  institution  before  resuming  his  ordinary  mode  of  life. 

W,  Cayley, 


MEDITERRANEAN  FEVER 
■  Syn.  Malta,  Rock  or  Neapolitan  Fever  ;  Undulant  Fever 

Definition. — An  endemic  pyrexial  disease,  occasionally  pre- 
vailing as  an  epidemic,  having  a  long  and  indefinite  duration  and 
an  irregular  course,  with  an  almost  invariable  tendency  to  undu- 
latory  pyrexial  relapses,  and  a  constant  occurrence  in  certain 
tissues  of  a  definite  species  of  micro-organism,  which  fulfils  Koch's 
postulates. 

Geographical  distribution. — It  is  widely  distributed  in  the 
countries  bordering  upon  the  Mediterranean,  south  of  latitude 
46°  N.,  and  along  the  Red  Sea  littoral.  Analogous  forms  of  fever, 
giving  a  serum  reaction  with  the  micrococcus  of  this  disease,  are 
also  met  with  in  parts  of  India,  China,  Africa,  and  America. 


MEDITERRANEAN   FEVER    .  iii 

Etiology. — The  disease  is  the  result  of  the  entrance  of  the 
micrococcus  melitensis  Vel  Brncii  into  the  tissues  of  the  human  body. 
This  organism  is  constantly  present  in  the  spleens  and  other  organs 
of  fatal  cases,  can  be  indefinitely  cultivated  artificially,  and  is  also 
pathogenic  to  monkeys. 

The  disease  is  not  directly  infectious  from  man  to  man.  There 
is  no  evidence  that  it  is  usually  disseminated  by  food  or  drink,  nor 
has  it  been  traced  to  inoculation  by  insects  or  otherwise.  There 
is,  however,  a  close  connection  between  the  occurrence  of  the 
disease  and  pollution  of  the  soil  in  or  around  dwelling  rooms  or 
under  tents,  with  the  fgeces  or  urine  of  patients  suffering  from  this 
fever. 

Its  prevalence  in  the  Mediterranean  coasts  is  in  exact  inverse 
proportion  to  the  amount  and  continuance  of  the  rainfall,  and  in 
direct  proportion  to  the  average  air  temperature  above  60°  F. 
The  disease  attacks  all  ages,  but  more  especially  those  between  ten 
and  thirty,  who  have  not  previously  suffered  from  it.  Sex,  length 
of  residence,  and  station  in  life,  have  apparently  only  an  indirect 
influence  on  its  prevalence.  The  initial  symptoms,  the  above  facts 
and  other  circumstantial  evidence,  lead  one  to  suspect  that  the 
virus  usually  enters  the  body  by  the  inspired  air,  and  leaves  it  by 
way  of  the  fseces  (and  urine  ?).  Though  not  present  in  clean  soil, 
the  micrococcus  seems  able  to  live  as  a  saprophyte  in  faecally 
polluted  soil.  It  is  not  supposed  that  the  virus  is  carried  far 
through  the  air,  a  distance  of  from  3  to  10  feet  being  sufficient  to 
account  for  the  majority  of  the  cases. 

The  incubation  period  is  probably  between  three  and  ten 
days. 

Symptoms. — The  writer  has,  for  convenience,  divided  over  a 
thousand  cases  he  had  treated  into  three  clinical  types,  indicative  of 
variations  in  severity  of  the  fever,  one  type  often  passing  into 
another.  In  the  malignant  type  the  onset  is  almost  sudden ;  the 
patient  complains  of  severe  headache,  "pains  all  over  him,"  nausea 
or  even  vomiting,  his  tongue  being  foul,  coated  and  swollen,  and 
his  breath  soon  becoming  very  offensive.  The  temperature  reaches; 
104°  or  105°  and  remains  more  or  less  continuously  high.. 
Diarrhoea,  with  most  offensive  stools,  may  be  present.  After  a  few 
days  in  this  condition  the  patient  passes  into  the  "  typhoid  state,"' 
the  lungs  become  choked,  the  pulse  weak,  and  hyperpyrexia  and. 
death  ensue.  The  bodies  of  such  fatal  cases  are  often  most 
offensive  and  described  as  "rotten."  In  these  days  of  energetic- 
treatment  such  cases-are  happily  rare.- .  - - 


112 


MANUAL  OF  MEDICINE 


Temperature  Curves  in  Two  Cases  of  Mediterranean 

Fever. 

Case  I. 


Date 

18 

19  20 

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Case  II. 


Date 

9 

10 

11 

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13 

nr 

15 

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17 

18 

19 

20 

21 

22 

23 

24 

25 

26 

27 

28 

29 

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Undulatory  type  with  well-marked  waves. 


MEDITERRANEAN   FEVER  113 

In  the  imdidatory  type  the  case  usually  commences  like  one  of 
enteric  fever  with  constipation,  followed  by  numerous  relapses. 
It  is  thus  marked  by  a  series  of  waves  or  undulations  of  remittent 
pyrexia,  separated  by  periods  of  abatement  or  absence  of  symptoms. 
At  any  stage  the  case  may  take  a  malignant  and  fatal  turn,  or  the 
pyrexia  may  gradually  subside  into  a  daily  intermittence  before 
convalescence.  The  pyrexial  curves  average  10  days,  the  primary 
one  being  usually  the  longest  (18-23  days),  there  being  from  one  to 
seven  waves  in  an  attack.      This  is  the  commonest  type  of  the  fever. 

In  the  intermittent  type  the  temperature  usually  falls  daily  be- 
tween midnight  and  2  a.m.  to  or  below  normal,  accompanied  by 
profuse  diaohoresis,  rising  slowly  but  steadily  about  1 1  a.m.  next 
day  to  var}'ing  heights,  without  rigor.  This  type  much  resembles 
the  hectic  pyrexial  curve  of  phthisis  or  other  suppuration.  If  the 
maximum  temperatures  be  accurately  recorded  each  day,  they  will 
be  found  to  form  undulations  similar  to  those  met  with  in  the 
former  type. 

Pyrexia  of  an  undulator}-  character,  unaccompanied  by  suppura- 
tion, is  the  one  constant  feature  of  this  disease.  The  initial 
symptoms  are  tightness  about  the  throat,  often  redness  of  the 
tonsils,  and  slight  swelling  of  the  submaxillary  and  cervical  glands, 
pain  in  the  muscles  of  the  neck  and  back,  nausea,  anorexia,  epi- 
gastric tenderness,  headache  and  foul  tongue.  The  usual  signs  of 
fever  supervene  with  especially  marked  dyspeptic  symptoms  and 
constipation.  Remissions  of  temperature  are  accompanied  by 
most  profuse  perspiration.  The  reflexes  are  increased ;  and  at  any 
stage,  but  usually  later  in  the  attack  or  during  convalescence,  acute 
sciatica  or  other  localised  neuritis  may  occur  in  any  position. 
Or  there  may  be  acute  effusion  into  one  or  more  joints,  or  acute 
orchitis.  Finally,  long  cases  may  be  reduced  to  an  anaemic, 
emaciated  and  bed-ridden  condition,  the  patient  being  sub'ect  to 
attacks  of  bronchial  catarrh,  cardiac  palpitation  or  neuralgic  com- 
plications on  the  slightest  chill,  change  of  weather  or  even  excite- 
ment. Disappointed  at  each  relapse  and  his  hair  fallen  off,  his 
whole  expression  becomes  the  picture  of  despondent  apathy,  his 
only  wish  being  to  get  away  to  England.  His  emaciated  appear- 
ance, profuse  night  sweats  with  intermittent  pyrexia  and  cough, 
remind  one  forcibly  of  phthisis,  a  diagnosis  which  is  often  errone- 
ously made.  However,  in  time  the  tongue  shows  signs  of  cleaning, 
the  temperature  falls  to  subnormal  and  the  corner  is  turned,  after 
which,  under  judicious  dietar}-  and  plenty  of  fresh  air,  he  regains 
weight  and  strength  with  wonderful  rapidity. 

VOL.  I  I 


114  MANUAL  OF  MEDICINE 

Prognosis. — Favourable  as  regards  danger  to  life  or  health, 
the  case  mortality  being  only  about  two  per  cent,  but  most 
unfavourable  as  regards  the  length  of  attack  and  consequent 
interference  with  livelihood  until  convalescence  is  complete.  The 
pyrexial  duration  (20  to  300  or  more  days)  averages  60  to  70  days. 
Previous  history  of  tuberculous,  cardiac  or  pulmonary  disease,  is 
unfavourable ;  while  the  actual  presence  of  cardiac  or  renal  disease, 
of  concurrent  anaemia,  of  phthisis  or  of  great  nervous  excitability, 
indicates  a  serious  prognosis.  The  only  reliable  sign  of  approach- 
ing convalescence  is  a  subnormal  temperature  for  a  few  days, 
followed  by  a  normal,  steady  temperature  when  accompanied  by  a 
clean  or  rapidly-cleaning  tongue. 

Second  attacks  are  rare.  It  is  not  certain  to  what  extent  one 
attack  protects  against  another,  but  it  seems  that  it  confers  some 
immunity. 

Morbid  anatomy. — The  naked  eye  post-mortem  appearances 
of  acute  and  rapidly  fatal  cases  are  those  of  intense  congestion, 
especially  marked  in  the  internal  organs,  the  spleen  being  enlarged, 
often  disorganised,  and  almost  liquefied  within  its  capsule.  In 
chronic  cases  there  are  the  signs  of  long-continued  irritation  of  the 
tissues,  similar  to  the  fibrotic  changes  consequent  upon  chronic 
alcoholism  or  plumbism. 

Diagnosis. — The  disease  can  be  definitely  diagnosed  from 
enteric  fever,  paludism,  phthisis,  liver  or  pelvic  abscess,  empyema 
and  other  suppurating  diseases,  rheumatic  affections  and  croupous 
pneumonia,  etc.,  by  the  reaction  of  the  blood  serum  of  true  cases, 
upon  living  or  dead  cultures  of  the  micrococcus  melitensis ;  ^  also 
by  the  local  and  special  symptoms  of  these  diseases,  and  the 
absence  from  the  blood  of  malarial  parasites.  The  serum  reaction 
is  often  the  only  reliable  sign,  so  closely  does  the  aisease  resemble 
enteric  fever  as  met  with  abroad. 

Prophylaxis. — The  institution  of  sound  water  drainage,  the 
avoidance  of  contaminated  ground  for  camping  purposes,  the 
prevention  of  pollution  of  the  soil  round  camps  and  buildings, 
due  attention  to  all  latrines  and  urinals,  proper  ventilation,  avoid- 
ance of  damp  and  overcrowding,  and  destruction  of  infected  stools 
and  urine  are  the  most  effectual  means  of  prevention.  It  is  also 
desirable  to  avoid  Mediterranean  towns  between  the  months  of 
May  and  October,  and  to  remember  that  this  region  is,  except  in 

^  For  technique,  see  Mediterranean,  Malta  or  Undulant  Fever  (author),  p.  158  ; 
Macmillan  and  Co.  1898  ;  and  Wright  in  Brit.  Med.  Journal,  1897,  vol.  i,  pp. 
139.  258. 


MEDITERRANEAN   FEVER  115 

the  hot  summer  months,  subject  to  sudden  changes  of  temperature 
and  that  the  air  is  very  moist,  necessitating  the  possession  of  the 
warmest  clothes,  an  extra  cloak  at  sundown,  and  of  always  sleeping 
in  flannel,  and  wearing  it  next  the  skin. 

Treatment. — No  agent  having  a  specific  action  upon  this  virus 
is  known  at  present.  We  have  primarily  to  treat  a  pyrexia,  and 
secondly  such  local  symptoms  as  may  be  present.  First  remove  the 
patient  to  sanitary  surroundings  ;  when  the  diagnosis  is  certain  open 
the  bowels  with  a  smart  purgative,  calomel  with  compound  jalap 
powder  for  choice.  Confine  the  patient  to  bed  so  long  as  the  high 
temperature  continues.  Let  him  have  as  much  fresh  air  as  is  com- 
patible with  avoidance  of  chills  and  the  fatigue  of  moving,  placing 
him,  when  possible,  in  his  bed,  at  least  during  the  daytime,  out  in  the 
open  air  on  a  verandah  or  elsewhere.  Provide  an  ample  supply  of 
night  clothes  of  some  absorbent  material  for  the  changes  necessitated 
by  the  excessive  diaphoresis.  Keep  the  temperature  at  or  below 
103°  F.  by  means  of  tepid  or  cold  sponging  or  packing.  Treat  any 
tendency  to  pneumonic  congestion  or  weak  cardiac  action  at  once  and 
energetically.  Attend  to  the  skin,  washing  it  daily  with  tepid  water 
containing  a  little  ammonia  or  vinegar.  Diet  to  be  fluid  so  long  as 
fever  is  present,  restricted  in  amount  when  that  is  high  and  abundant 
when  low.  Chronic  cases,  with  mild  intermittent  temperature,  can 
often  digest  and  benefit  by  scrambled  eggs,  or  fish,  etc.,  for  breakfast 
when  the  temperature  is  normal,  but  not  later  in  the  day  when  it 
rises.  The  tongue  is  the  best  guide  as  to  the  suitability  or  otherwise 
of  dietary.  In  the  early  morning,  about  5  or  6  a.m.,  a  glass  of 
milk  should  be  given  (with  or  without  whisky)  as  a  routine  practice, 
the  patient  being  extremely  depressed  at  that  time.  Subnitrate  of 
bismuth  should  be  given  for  gastritis  or  vomiting,  combined  if 
necessary  with  beef  juice,  peptonised  foods  and  champagne.  If 
diarrhoea  is  present,  beef  tea  is  contra-indicated.  For  diarrhoea 
resulting  from  irritation  in  the  colon,  warm  enemata  of  starch  and 
opium  are  useful.  Fresh  fruit  and  lemonade  should  be  given,  stewed 
prunes  and  baked  apples  being  utilised  to  lessen  constipation. 
Eff'usion  into  joints  and  neuralgic  pains  are  best  treated  by  moist 
warm  local  applications,  followed  by  belladonna  and  by  placing  the 
patient  between  blankets  and  enveloping  the  part  in  cotton  wool  and 
flannel.  Though  the  bed  pan  is  necessary  during  acute  pyrexia,  the 
close  stool  may  be  used  in  the  chronic  intermittent  stages,  provided 
the  patient's  hips,  etc.,  are  carefully  protected  from  cold.  Quinine 
and  arsenic  do  harm  in  the  acute  stages ;  but  during  convalescence 
quinine  may   be  given  in  small  doses  as   a  tonic,   or   better    still 


ii6  MANUAL  OF  MEDICINE 

Blaud's  pills,   with  plenty  of  out-door  air,  full  diet   and  stout,  but 
fatigue  and  mental  worry  must  be  avoided. 

During  the  autumn  and  winter  months  cases  do  better  away  from 
England  and  where  they  can  be  out  of  doors,  in  hill  towns  of  Italy  or 
Sicily,  or  in  the  dry  climate  of  Egypt.  During  spring  and  summer  a 
change  to  England,  Switzerland,  the  Italian  Alps  or  similar  places  is 
most  important  after  the  first  acute  stage  has  passed.  A  dry  place 
is  essential,  bracing  but  not  exposed.  A  sea  voyage  is  often  most 
beneficial  to  long  chronic  cases,  especially  when  the  patients  are 
able  to  get  on  deck. 

Other  treatment  should  be  on  general  lines,  such  as  is  usual  in 
enteric  fever,  for  the  acute  stages,  and  that  now  recommended  for 
phthisis  during  the  chronic  stages. 

M.   Louis  Hughes. 


CHOLERA 


An  acute  infectious  disease,  determined  by  a  specific  organism 
termed  the  "comma"  bacillus,  which  is  met  with  on  and  between 
the  epithelial  cells  of  the  intestinal  mucosa  and  in  the  contents  of  the 
bowels,  and  characterised  by  intestinal  evacuations  of  a  watery  con- 
sistence, by  violent  vomiting,  by  muscular  cramps,  by  suppression 
of  urine,  by  extreme  and  rapid  prostration,  and  by  a  high  mortality. 
Endemic  in  Lower  Bengal,  and  perhaps  in  other  parts  of  Asia, 
cholera  frequently  assumes  an  epidemic  character,  spreading  to 
almost  every  part  of  the  world. 

History. — Although  cholera  was  well  known  in  Asia  and  Europe 
from  early  times,  the  disease  was  first  definitely  described  during 
the  epidemic  of  1817  by  Europeans  in  India.  In  1830  the  disease 
visited  Europe  for  the  first  time  during  the  present  century,  and 
since  then  it  has  reappeared  in  the  following  years:  1845,  1853, 
1863,  1873,  1884,  1892,  on  each  occasion  lasting  for  one,  two  or 
three  or  more  years  before  it  finally  disappeared.  The  first  three 
epidemics  only  were  general,  every  nation  in  Europe  being  severely 
visited  by  cholera,  but  since  1865  the  outbreaks  have  been  very 
limited,  a  few  towns  only  in  several  countries  being  the  sole  sufferers. 

Geographical  distribution. — Cholera  is  an  Asiatic  disease, 
and  belongs  more  particularly  to  certain  areas  in  Lower  Bengal,  so 
much  so  that  in  this  region  cholera  is  held  to  be  endemic.     The 


CIIJLERA  117 

attempts  to  focus  the  origin  of  all  cholera  epidemics  in  Bengal  is 
probably  based  on  ignorance,  as  cholera  is  prevalent  in  many  other 
Asiatic  countries  at  some  period  of  almost  every  year.  Geological 
conditions  play,  if  any,  but  a  secondary  part  in  determining  the 
presence  of  cholera ;  elevation  per  se  has  less  influence  than  used 
to  be  assigned  to  it.  It  is  a  disease  that  travels  along  the  lines 
of  human  traffic  be  they  by  road  or  rail,  by  steamships  or  river 
boats.  Cholera  has  visited  both  hemispheres  and  spread  almost 
universally,  yet  there  are  some  regions  even  in  India,  such  as 
Mooltan  and  Pondicherry,  where  immunity  is  more  or  less  com- 
plete. Australia,  New  Zealand,  the  Cape  of  Good  Hope,  the 
Andaman  Islands  in  the  Bay  of  Bengal,  and  the  majority  of  the 
islands  of  the  Pacific  have  never  been  visited  by  cholera  in  an 
epidemic  form. 

Etiology. — Predisposing  causes:  season,  exercises,  a  direct  in- 
fluence on  the  presence  of  cholera  in  all  countries  to  the  north  of 
the  Equator.  July  and  August  are  the  months  during  which  it 
attains  its  maximum  of  virulence  ;  but  it  may,  and  does  occur  during 
the  winter  months  in  India  and  in  Russia,  where  it  has  continued 
throughout  the  snow  and  Arctic  cold  of  the  severest  winters.  In- 
sanitary localities  are,  as  a  rule,  subject  to  be  severely  visited  by 
cholera ;  whether  the  insanitary  state  be  due  to  overcrowding,  foul 
drains,  water-logged  soil,  absence  of  drains,  polluted  water  supply, 
leaking  cesspits,  or  to  all  combined,  each  is  warranted  when  cholera 
is  imminent  to  increase  the  death-rate  in  direct  ratio  to  the  amount 
of  insanitation.  A  new  arrival  is  more  liable  to  be  attacked  than 
the  native  or  old-time  European  resident  when  cholera  is  prevalent. 
Women  are  less  liable  to  cholera  than  men,  and  infants  enjoy  a 
marked  immunity.  Alcoholic  intemperance,  bad  or  insufficient 
food,  fatigue  from  whatever  cause,  fear  of  infection,  debility  brought 
about  by  illness  from  any  cause,  be  it  climatic,  malarial  or  "  con- 
stitutional," predisposes  the  individual  to  attacks  of  cholera  when  it 
is  epidemic.  Europeans  are  most  liable  to  a  seizure  of  cholera 
during  the  night,  and  natives  after  a  full  meal.  In  the  tropics 
the  former,  intolerant  of  the  heat  at  night,  unconsciously,  it  may 
be,  throws  off  his  bed  clothing  and  renders  himself  more  liable  to 
abdominal  chill  at  a  period  when  his  own  temperature  is  at  its 
lowest  and  the  temperature  of  the  air  is  at  its  minimum.  The 
native  is  seldom  so  affected,  and  it  has  been  repeatedly  observed 
that  a  full  meal,  especially  of  fish  or  oysters,  serves  as  a  predis- 
posing cause. 

An  attack  of  cholera  affords   protection  for  a  time  only.     A 


ii8  MANUAL   OF   MEDICINE 

second  attack  during  any  single  epidemic  is  well-nigh  unknown, 
but  a  previous  attack  confers  no  immunity  from  cholera  during 
future  outbreaks. 

The  means  by  which  tlie  poison  is  i?itrodiiced  into  the  body  is 
at  the  present  day  held  to  be  by  pollution  of  the  drinking  water 
by  cholera  evacuations.  In  1854,  Dr.  Snow,  by  his  careful  investi- 
gations, estabUshed  the  power  of  water  contaminated  by  cholera 
evacuations  to  cause  cholera,  and  many  instances  could  be  cited 
in  proof  of  the  principle  which  he  first  enunciated. 

It  is  possible  also  that  food,  merchandise,  insects  such  as  flies, 
clothing,  etc.,  may  serve  as  a  medium  whereby  cholera  can  be  com- 
municated, but  although  these  may  serve  to  infect  individuals,  they 
cannot  ser\-e  as  a  general  infecting  agency,  unless  the  stools  of  one 
or  more  of  those  so  suffering  reach  the  drinking  water  used  by  the 
community. 

Bacteriology. — The  introduction  of  the  specific  toxin  into  the 
body  is  the  one  exciting  cause  of  cholera.  Koch,  during  the 
Eg}-ptian  epidemic  in  1883,  separated  a  bacillus  from  the  stools 
and  intestines  of  persons  suffering  from  Asiatic  cholera.  This  micro- 
organism is  known  from  its  shape  as  the  "  comma  "  bacillus,  and 
its  presence  in  the  stools  in  quantity  is  a  conclusive  proof  that  the 
person  is  suffering  from  Asiatic  cholera. 

Methods  of  microscopic  examination. — {a)  Smear  a  small  quantity 
of,  or  a  mucous  film  from,  a  cholera  evacuation  on  a  warm  slide  ;  allow 
this  to  partially  dry  ;  drop  a  few  drops  of  a  weak,  freshly  prepared, 
watery  solution  of  methyl  violet  on  the  specimen,  and  after  fifteen 
seconds  run  the  staining  fluid  off;  superimpose  a  cover-glass,  pressing  it 
down  lightly  ;  lay  a  piece  of  filter  paper  on  the  cover-glass  and  slide,  so 
that  the  superfluous  fluid  at  the  cover  edge  is  absorbed  ;  examine  with  a 
one-tenth  or  one-twelfth  inch  oil  immersion  lens.  By  this  procedure 
the  bacilli  are  stained,  their  vitality  and  power  of  movement  are  not 
checked,  more  especially  if  the  slide  be  maintained  at  a  temperature 
slightly  above  that  of  the  body. 

{b)  Place  a  small  quantity  of  the  cholera  evacuation  on  a  cover- 
glass  ;  superimpose  another  clear  cover-glass  and  pull  the  two  asunder  ; 
dr\'  the  specimen  in  the  usual  way  ;  float  the  cover-glasses,  smeared 
side  downwards,  on  a  watery  solution  of  fuchsin  in  a  porcelain  dish, 
and  warm  over  a  spirit-lamp  flame  for  ten  minutes.  Dry  the  pre- 
paration and  mount  it  for  microscopic  examination. 

(<:)  For  more  precise  investigation  the  bacillus  may  be  stained  by 
Loffler's  method,  which,  though  a  tedious  process,  gives  more  precise 
results,  and  by  it  the  flagella  are  best  defined. 


CHOLERA  119 

The  comma  bacillus^  cholera  vibrio,  or  spiriihwi  chokrcB  AsiaticcE, 
present  in  the  stools  and  in  the  intestines  of  cholera  patients,  but 
never  found  in  the  blood  or  tissues,  has  the  following  microscopic 
characters : — 

The  typical  bacillus  measures  i  to  2  /x  in  length  and  0.5  to  0.6  /x 
in  thickness.  When  stained  the  parasite  shows  one,  two,  or  three, 
more  deeply  coloured  spots,  suggesting  spores,  although  sporulation 
has  never  been  observed.  The  bacilli,  which  are  usually  seen  to  be 
separate,  may  coalesce  so  as  to  form  an  arc ;  but  when  the  commse 
are  joined  with  their  curves  in  a  reverse  direction  the  body  appears 
curved  like  an  "  S."  In  some  preparations  from  cultures  the  bacilli 
may  coalesce  by  their  extremities,  so  as  to  form  an  undulating 
thread-like  line  (Plate  II.). 

When  stained  the  comma  bacillus  exhibits,  during  certain  as  yet 
undetermined  periods  of  its  existence,  extremely  fine  flagella.  In 
some  specimens  but  one  is  met  with,  although  a  flagellum  at  each 
end  would  seem  to  be  the  rule.  The  flagella  may  exceed  in  length 
the  body  of  the  bacterium,  and,  although  very  delicate,  confer  upon 
the  organism  active  "  spirillum-like  "  movements. 

But  the  comma  bacillus  is  not  the  definite  entity  one  anticipates 
from  reading  Koch's  original  description.  In  the  first  place,  there 
are  several  bacilli  which  bacteriologically  and  anatomically  resemble 
the  comma  bacillus  of  Koch.  Of  these  the  best  known  are  the 
bacilli  of  cholera  nostras,  certain  bacilli  met  with  in  the  mouth,  and 
even  in  so-called  "  fresh  "  water.  Nor  do  the  comma  bacilli  of 
cholera  always  maintain  the  power  of  infection  claimed  for  them. 
Cultures  of  the  comma  bacilli  from  cholera  stools  have  been 
swallowed  by  several  experimenters  with  negative  results.  Again, 
the  bacilli  have  not  always  been  met  with  in  the  stools  of  cholera 
patients,  and  moreover  bacilli,  comma  in  shape  and  bearing 
seemingly  specific  characteristics,  have  been  frequently  met  with  in 
the  stools  of  healthy  persons.  An  accumulation  of  observations  of 
a  like  nature  have  thrown  doubt  upon  Koch's  dogma  that  the 
comma  bacillus  is  the  only  essential  element  required  to  produce 
an  attack  of  cholera.  Still,  for  clinical  purposes  the  presence  of  the 
comma  bacillus  in  quantity  in  the  stools  justifies  the  conclusion 
that  a  specific  disease — Asiatic  cholera — is  present. 

Culture,  methods  a/td  characters.  —  The  cholera  bacillus  yields  a 
well-nigh  specific  appearance  in  culture  media.  It  will  not  grow  on 
sour  or  acid  media  but  thrives  luxuriantly  on  broth,  milk,  or  serum  that 
has  been  rendered  alkaline.  Agar -agar  is  not  liquefied  during  the 
process,  but  gelatine  is  so  readily,  and  it  is  for  purposes  of  diagnosis 


I20  MANUAL  OF  MEDICINE 

tlie  most  suitable  culture  medium.  When  gelatine  is  seeded  by 
punctures  and  maintained  at  a  temperature  of  20°  C,  within  twenty-four 
hours  a  delicate  white  cloud  forms  along  the  puncture  tracts.  The 
gelatine  liquefies,  and  in  forty-eight  hours  the  liquefied  areas  assume  a 
characteristic  funnel  shape  at  the  upper  part.  By  the  fourth  day  a 
pronounced  thread-like  process  extends  downwards  into  the  medium. 
The  thread  is  spiral  and  presents  enlargements  in  its  length  like  the  links 
of  a  cable.  The  whole  of  the  upper  or  seeded  portion  of  the  gelatine 
liquefies,  and  the  contents  of  the  tube  present  the  following  appearance: — 
Lying  on  the  top  is  a  grayish  scum  consisting  of  involuted  or 
degenerate  forms  of  the  comma  bacillus  ;  beneath  the  scum  is  the  clear 
liquefied  gelatine  ;  and  below  this,  and  resting  on  the  solid  gelatine, 
is  a  yellowish-white  layer  of  cholera  bacilli.  When  gelatine  plate- 
cultures  are  employed,  the  various  colonies  are  seen  to  be  irregular  in 
shape  and  size,  and  to  give  a  granular,  shining,  ground -glass -like 
appearance  to  the  gelatine  medium.  A  faint  roseate  tinge  is  imparted 
to  the  growth  in  the  later  stages,  a  colour  considered  to  be  characteristic 
of  cholera  bacilli.  When  grown  on  sections  of  sterilised  potatoes,  at  a 
temperature  of  between  30"  C.  and  35°  C,  the  exposed  surface  of  the 
potato  is  speedily  covered  by  a  copious  moist-looking  growth  of  a  dirty 
gray  or  light  brown  colour,  altering  to  colours  of  varying  tints  m  the 
course  of  a  few  days. 

Incubation. — After  exposure  to  cholera,  infectious  symptoms 
may  develop  in  a  few  hours.  Three  days  is  the  usual  period  of 
incubation,  but  it  may  extend  to  as  many  as  ten  days.  This 
question  has  a  direct  bearing  on  qiiara7iti7ie^  in  fact  all  quarantine 
regulations  against  cholera  are  founded  on  the  determination  of  this 
period.  Should  a  ship  be  ten  days  out  from  a  cholera-infected  port, 
and  no  cases  of  cholera  have  occurred  on  board  during  the  voyage, 
it  is  foolish  to  impose  a  further  period  of  quarantine  upon  the 
passengers. 

Symptoms. — It  is  customar}'  to  divide  an  attack  of  cholera 
into  four  stages,  viz.  :  (i)  the  Premonitory  stage;  (2)  the  Evacuation 
stage  ;  (3)  the  period  of  Collapse  or  Algide  stage ;  and  (4)  the  stage 
of  Reaction.  These  are  more  or  less  fanciful  divisions,  as  in  a  large 
number  of  cases  the  onset  is  sudden,  the  development  explosive, 
and  death  a  matter  of  a  few  hours. 

T\\^  premojiitory  diarrhcea  of  cholera  is  a  condition  more  often 
described  than  seen,  and  how  far  it  is  an  essential  stage  of  the 
disease  or  an  accidental  predisposing  condition  is  doubtful. 

The  onset  of  cholera  is  marked  by  a  violent  intestinal  flux, 
attended  by  a  feeling  of  sinking  in  the  epigastrium  and  a  marked 
loss  of  strength. 


CHOLERA  121 

The  siools  in  cholera  are  characterised  by  their  consistence, 
bulk,  frequency,  and  the  force  with  which  they  are  expelled.  At  first 
they  consist  of  copious  watery  evacuations  bearing  a  resemblance  to 
faeces,  but  they  speedily  lose  every  trace  of  faecal  matter  and  become 
the  typical  "  rice-water  "  stools  characteristic  of  the  disease.  These 
evacuations,  on  being  allowed  to  stand,  separate  into  a  sediment 
and  a  whey-like  fluid.  The  former  consists  of  active  amoeboid  cells, 
epithelium,  hyaline,  and  granular  cells,  the  bacteria  which  usually 
inhabit  the  intestine  and  the  specific  comma  bacillus.  The  fluid 
has  a  specific  gravity  of  1005  to  10 10,  and  gives  a  neutral  or  faintly 
alkaline  reaction,  and  contains  a  little  albumen.  The  bulk  of  the 
motion  is  at  times  surprising ;  well-nigh  a  quart  may  be  passed  at 
a  time.  The  frequency  of  the  calls  to  defecate  allows  of  but  little 
time  to  remove  one  bed  pan  before  another  is  wanted.  Owing  to 
the  violent  contractions  of  the  muscular  walls  of  the  intestine  the 
contents  of  the  bowel  are  expelled  with  great  force,  leaving  the 
patient  prostrate  for  a  few  minutes,  or  until  the  next  motion  threatens. 

Copious  vomiting  without  great  effort  sets  in,  the  vomited  matters 
being  first  the  stomach  contents,  but  afterwards  consisting  of  thin 
fluid  containing  a  little  mucus.  Cramps  in  the  limbs  and  muscles 
of  the  abdomen  give  rise  to  considerable  pain,  the  patient  crying 
out  in  dread  when  a  muscular  spasm  comes  on.  Thirst  is  present 
almost  from  the  first,  but  the  patient  vomits  whatever  he  drinks  to 
relieve  it.  After  a  few  hours  the  strength  of  the  patient  reaches  a 
low  ebb.  The  tongue  looks  sodden,  the  gums  pale ;  the  surface  of 
the  body  feels  cold,  and  if  the  temperature  is  taken  in  the  axilla  it 
will  be  found  lowered  ;  it  may  be  two,  three,  or  four  degrees  below 
the  normal.  The  pulse,  which  is  accelerated  from  the  onset,  soon 
becomes  feeble,  then  thready,  and  in  very  serious  cases  cannot  be 
felt  at  the  wrist  or  even  in  the  arm.  The  heart  sounds,  when  the 
disease  is  well  -advanced,  are  scarcely  to  be  heard,  and  the  cardiac 
impulse  disappears.  The  breathing  is  disturbed,  becoming  gasping, 
the  patient  calling  out  for  air  ;  the  voice  is  reduced  to  a  whisper ;  the 
expired  air  is  cold ;  there  is  much  restlessness,  tossing  about,  and 
throwing  off  the  bed-clothes.  The  urine,  which  is  at  first  high 
coloured,  soon  becomes  scanty  and  albuminous,  and  may  be 
altogether  suppressed.  Should  this  state  continue,  a  grave  con- 
dition is  indicated. 

When  the  stage  of  collapse  supervenes  the  evacuations  may  cease, 
though  the  vomiting  may  continue,  and  the  cramps  give  rise  to 
no  expression  of  pain.  The  skin  appears  cyanosed  and  wrinkled, 
and  when  seized  between  the  finger  and  thumb  the  fold  disappears 


122  MANUAL  OF  MEDICINE 

quite  slowly.  The  face  looks  shrivelled  and  lined,  the  eyeballs 
sunken,  the  eyelids  are  but  half  closed,  and  the  nose  looks  pinched 
and  pointed,  the  features  being  so  changed  as  to  render  the  indi- 
vidual well-nigh  unrecognisable.  The  mental  condition,  which  in 
the  early  stage  is  quite  clear,  in  the  later  stages  changes  to  one  of 
apathy.  Whilst  the  thermometer  in  the  mouth  and  axilla  registers 
4°  F.  to  6°  F.  below  the  normal,  the  rectal  temperature  rises  usually 
to  103°  F.  or  105°  F.  In  several  instances,  in  the  experience  of  the 
writer  in  Egypt  and  China,  the  rectal  temperature  reached  to  be- 
tween 108"  F.  and  109'^  F.  half  an  hour  before  death. 

Should  death  be  delayed  beyond  the  stage  of  collapse,  what  is 
termed  the  "  tepid  "  stage  supervenes.  The  body  temperature  rises 
to  about  the  normal :  even  the  pulse  may  return  at  the  wrist ;  the 
purging  and  vomiting  entirely  cease  and  the  patient's  features  and 
complexion  become  more  natural;  but  the  pupils  remain  fixed,  the 
cornea  hazy,  the  eyeballs  sunken,  and  in  a  comatose  state  life 
becomes  extinct.  There  are  practically  no  recoveries  from  this 
stage,  although  to  the  inexperienced  it  would  seem  that  a  favourable 
turn  has  set  in. 

When  the  attack  is  followed  by  reaction.,  the  surface  of  the  body 
becomes  warmer,  the  colour  begins  to  return,  the  pulse  and  voice 
recover,  urine  is  passed,  and  after  a  sleep  the  patient  wakes  refreshed. 
On  the  other  hand,  when  the  stools  are  passed  involuntarily,  when 
the  brachial  pulse  or  even  the  carotid  pulse  disappears,  when 
hiccough  becomes  distressing,  and  the  temperature  falls  to,  say,  94°, 
whilst  the  temperature  of  the  rectum  rises  perhaps  to  105°  or  107° 
F.,  a  fatal  issue  is  at  hand. 

Sequelse.  —  Convalescence,  following  an  attack  of  cholera, 
depends  upon  the  duration  and  acuteness  of  the  attack.  In  mild 
cases  convalescence  is  rapid,  but  in  severe  and  prolonged  cases  the 
intestines  may  remain  irritable  for  months.  Many  ailments  and 
conditions  may  succeed  an  attack  of  cholera,  such  as  an  urticaria 
or  roseola  choleraica,  convulsions,  especially  in  children,  enteritis, 
haemorrhage  from  the  bowel,  parotitis,  anaemia,  insomnia,  al- 
buminuria, sloughing  of  the  cornea  and  scrotum,  and  pulmonary 
thrombosis.  Females  frequently  abort  during,  or  very  soon  after  an 
attack. 

Diagnosis. — Diarrhoea  from  any  cause,  which  is  attended  by 
lividity  of  complexion,  mental  anxiety  and  epigastric  sinking,  is 
apt  to  be  styled  "  choleraic."  Any  septic  or  poisonous  material 
taken  as  food  may  set  up  symptoms  simulating  Asiatic  cholera; 
but   it   is    only    by  bacteriological   cultivation  and  by  microscopic 


CHOLERA  123 

examination  of  the  intestinal  dejecta  that  the  actual  existence  of 
true  (Asiatic)  cholera  can  be  conclusively  diagnosed. 

Prognosis. — Persons  attacked  by  cholera  at  the  commence- 
ment of  an  epidemic  are  in  greater  danger  than  those  seized  when 
the  epidemic  is  on  the  wane.  Children,  persons  in  advanced  years, 
chronic  sufferers  from  any  form  of  visceral  disease,  are  less  able 
to  withstand  the  onset  of  cholera  than  are  young  and  middle-aged 
persons  in  good  health.  Yet  the  strongest  men  may  succumb 
speedily.  The  writer  knew  of  an  engine-driver,  in  Eg}'pt  in  1883, 
who  started  on  his  engine  at  Alexandria  in  perfect  health,  die 
before  he  reached  Kaffir-Zayat,  halfway  to  Cairo,  the  journey  lasting 
only  two  and  a  half  hours. 

Mortality. — The  death-rate  of  different  epidemics  varies,  and 
the  case  mortality  at  the  commencement  and  end  of  an  outbreak 
shows  different  degrees  of  virulence.  It  may  be  taken  as  a  rule 
that  half  the  persons  attacked  by  cholera  die,  the  proportion  during 
the  earlier  part  of  the  epidemic  being  about  65  per  cent  of  those 
attacked,  and  during  the  later  stages  35  per  cent. 

Post-mortem  appearances. — As  may  be  gathered  from  the 
symptoms,  the  body  generally  will  present  a  shrunken  appearance 
after  death.  The  rectal  temperature  usually  rises  for  the  first  half 
hour ;  rigor  mortis  sets  in  ver}'  early — within  an  hour  or  two,  and 
muscular  contractions  may  distort  the  limbs  and  cause  them  to 
change  their  position.  The  stomach  is  usually  empty,  though  a 
considerable  quantity  of  food  may  remain  in  it  in  spite  of  in- 
cessant and  copious  watery  vomiting.  The  intestines  contain 
some  fluid  matter  with  mucous  material  intermixed.  The  mucous 
surface  of  the  alimentar}-  canal  looks  sodden,  bleached  in  parts, 
and  congested  in  others,  and  the  mucous  and  submucous  coats 
may  be  easUy  peeled  from  the  intestinal  walls.  The  solitary  and 
agminate  glands  are  swollen.  The  gall  bladder  is  distended  with 
bile,  the  liver  and  kidneys  appear  duskily  congested  and  full  of 
blood,  and  the  spleen  of  the  same  colour  may  be  either  enlarged 
or  diminished  in  size.  The  large  veins  of  the  trunk,  the  right 
side  of  the  heart,  and  the  pulmonar}'  arteries  are  usually  distended 
with  blood,  whilst  the  limb  veins  are  empty.  The  lungs  are 
pale,  and  seem  as  if  contracted  and  drawn  in  towards  their 
roots ;  the  muscles  of  the  limbs  and  trunk,  when  cut  into,  present 
at  times  a  dark,  violet-tinged  appearance,  but  in  other  cases  they 
look  pale  and  bleached.  It  is  not  uncommon  to  find  muscles 
ruptured,  the  result  of  the  severe  cramps  and  spasms  during  life. 
Should  the  patient  not  have  succumbed  until  the  period  of  reaction 


124  MANUAL  OF  MEDICINE 

has  set  in,  symptoms  of  congestion  in  the  lungs,  and  of  the 
intestines,  or  even  inflammation  of  these  organs,  may  be  met  with. 

Treatment. — Prophylactic  treatment  during  a  threatened  epi- 
demic of  cholera  resolves  itself  into  the  individual  efforts  of  house- 
holders to  procure  boiled  water  for  drinking,  for  washing  utensils, 
and  for  baths.  Milk  should  be  scalded  or  boiled  before  being 
consumed,  and  locally  manufactured  aerated  waters  should  be 
eschewed.  The  further  care  to  be  taken  is  strict  attention  to  diet, 
which  should  be  as  simple  as  possible,  and  well  cooked.  Unripe 
and  rotting  fruit  should  be  forbidden,  but  fruit  in  season  and  in 
good  condition  should  be  allowed.  The  writer,  by  removing  the 
restrictions  against  the  consumption  of  fruit  in  good  condition, 
in  the  towns  under  his  care  in  Egypt  in  1883,  found  immediate 
benefit  therefrom.  To  the  poor  in  Egypt  and  most  Oriental 
countries  fruit  is  a  stable  means  of  subsistence,  and  by  withholding 
it  entirely  the  native  is  more  or  less  reduced  to  wcU-nigh  starvation 
point ;  and  inanition  is  the  handmaiden  of  cholera. 

Above  all  is  it  imperative  to  disinfect  the  dejecta  of  cholera 
patients ;  and  not  only  should  the  stools  be  dealt  with,  but  even 
the  vomited  matters,  the  soiled  clothing  and  bedding.  The 
utensils  into  which  the  patient  evacuates  should  contain  a  potent 
disinfectant  such  as  perchloride  of  mercury  (1-2000),  or  carbolic 
acid  (1-20).  The  evacuations  must  be  covered  completely  by  the 
disinfecting  fluid,  removed  from  the  sick-room,  and,  where  possible, 
buried  at  least  three  feet  deep  in  the  ground  in  a  place  remote 
from  possibility  of  contaminating  wells.  On  no  account  must  the 
evacuations  be  thrown  on  the  surface  of  the  ground  near  the  house, 
into  open  drains,  cesspools  or  middens.  Where  a  water  carriage 
system  is  effective  they  may  be  consigned  to  the  sewer,  which 
ought  to  be  frequently  flushed  by  a  disinfectant ;  the  ferrous 
sulphate  (i  oz.  to  i  pint)  is  eminently  satisfactory  for  the  purpose. 
Clothing  and  bedding  are  to  be  burnt ;  and  should  the  patient  die 
the  body  ought  to  be  cremated,  or,  when  that  is  inexpedient,  the 
remains  should  be  coffined  in  charcoal,  buried  at  least  six  feet  in  the 
ground  and  covered  by  lime  before  the  earth  is  replaced. 

Treatment  by  anti-chokraic  inocii/ations. — As  a  preventive  measure 
in  cholera,  inoculations  by  a  specially  prepared  virus  have  been 
systematised  and  practised  by  Haffkine  in  India.  By  his  method 
protection  against  cholera  is  afforded  by  "  acclimatising "  the 
system,  first  to  a  weak,  and  afterwards  to  a  strong  cholera  poison. 
A  pure  culture  of  the  weak  or  attenuated  virus  is  grown  in  a 
medium  (agar),  at  a  temperature  of  39°  C, ;  a  constant  aeration  being 


CHOLERA  125 

maintained  during  the  process.  The  strong  or  "  exalted "  pure 
culture  is  grown  in  the  peritoneal  cavities  of  a  series  of  guinea-pigs. 
As  each  animal  dies  the  fluid  in  the  peritoneal  cavity  is  removed 
and  transferred  to  another,  and  so  on  through  a  series  of  t\Yenty  or 
thirty  guinea-pigs,  until  a  maximum  toxicity  is  obtained.  From 
the  pure  cultures  the  respective  "weak"  (first)  and  "exalted" 
(second)  vaccines  are  prepared  by  cultivation  on  agar  and  conversion 
into  emulsions  by  superimposing  a  layer  of  broth  with  which  the 
growth  is  intimately  mixed.  In  this  form  the  respective  "  vaccines  " 
may  be  used, — "  Uving  vaccines  " ;  or  they  may  be  treated  before 
being  injected  by  the  addition  of  dUute  carbolic  acid,  "  carbolised 
vaccine,"  by  which  process  the  bacilli  are  killed.  In  the  one  case 
the  baciUi  and  their  toxins  are  injected  together,  and  in  the  other 
the  toxins,  deprived  of  their  bacilli,  are  employed.  As  in  the 
"  living  vaccines  "  the  bacilli  die  immediately  after  the  fluid  is  in- 
jected subcutaneously,  the  choice  of  either  form  seems  immaterial. 

Under  strict  precautions  to  ensure  sterility  during  the  operation 
the  attenuated  vaccine  is  injected  under  the  skin  of  one  flank, 
and  on  the  fourth  or  fifth  day  afterwards  the  stronger  vaccine  is 
injected  into  the  opposite  flank.  The  quantity  used  is  one  cubic 
centimetre  for  an  injection. 

The  signs  and  symptoms  produced  by  inoculation  with  Haffkine's 
serum  appears  some  three  hours  after  the  hypodermic  injection  has 
been  given.  Tenderness  is  experienced  at  the  seat  of  the  puncture 
and  a  slight  oedema  extends  for  some  little  distance  around  ;  a  febrile 
disturbance  and  consequent  headache,  loss  of  appetite,  and  general 
feeling  of  lassitude  is  set  up,  which,  however,  pass  off  within  forty- 
eight  hours,  and  by  the  fourth  day  all  the  signs  at  the  seat  of  injection 
disappear.  A  similar  train  of  symptoms  is  set  up  after  the  second 
inoculation,  but  the  febrile  disturbance,  although  of  shorter  duration, 
is  more  acute. 

Repeated  and  careful  experiments  in  animals  con\-inced  Haffkine 
of  the  efficacy  and  safety  of  the  remedy,  and,  seeing  that  up  to  the 
present  moment  well-nigh  100,000  persons  have  been  inoculated 
without  any  untoward  result,  the  safety  of  the  remedy  may  be 
regarded  as  proved.  Haffkine  published  the  results  of  his 
inoculations  in  a  paper  read  before  the  Royal  Society  (June  1899). 
He  states  that  some  8000  persons  w-ere  inoculated  with  the 
prophylactic  serum  in  Calcutta,  and  for  two  years  observations 
were  made  as  to  the  relative  advantages  derived  therefrom.  The 
majority-  of  the  inoculated  resided  in  the  san"e  neighbourhood,  and 
in  many  instances  in  the  same  house  with  members  of  the  family 


126  MANUAL  OF  MEDICINE 

who  had  not  been  inoculated.  Whilst  the  uninoculated  developed 
cholera  in  a  marked  manner,  the  inoculated  showed  practically 
complete  protection  until  the  420th  day,  when  cholera  began  to 
spread  amongst  them.  Moreover,  Haffkine  showed  that  it  was  only 
as  a  temporary  prophylactic  that  the  inoculation  served,  for  the 
proportion  of  deaths  to  cases  amongst  the  inoculated  and  the 
uninoculated  remained  the  same.  The  efficacy  of  the  remedy 
against  cholera  is  still  on  its  trial,  but  there  is  every  indication 
that  a  prophylactic  remedy  of  great  value  has  been  discovered. 

Medicinal  treatment. — When  diarrhcea  occurs  whilst  a  cholera 
epidemic  is  incident  means  should  be  taken  to  check  it.  For  such 
purposes  many  drugs  are  recommended ;  some  authorities  claiming, 
quite  unjustifiably,  well-nigh  specific  action  for  their  plan  of  treatment. 
The  writer  can  speak  from  experience,  approvingly,  of  Macnamara's 
pill  of  I  grain  of  opium  and  4  grains  acetate  of  lead  given  early  in 
the  disease.  Chlorodyne  in  30  drop  doses  has  many,  perhaps  most 
advocates  ;  others  recommend  5  to  10  grains  tannic  acid,  whilst  some 
prescribe  20  minims  of  spirit  of  camphor,  or  10  grains  of  Dover  powder, 
or  20  minims  laudanum  with  3  grains  of  Cayenne  pepper;  the  drug 
being  repeated  at  short  intervals  as  symptoms  necessitate.  There  is 
no  doubt  that  diarrhoea  can  be  arrested  by  one  or  other  of  these 
remedies  during  a  cholera  epidemic,  as  at  other  times,  but  whether 
the  flux  of  true  cholera  can  thus  be  checked  is  doubtful. 

When  cholera  has  reached  the  second  or  evacuation  stage  no 
medicinal  or  other  forms  of  treatment,  if  we  exclude  anti-choleraic 
inoculations,  possess  a  specific  action.  The  medicinal  treatment  of 
cholera  is  purely  empiric,  and  one  has  to  fall  back  on  the  time-worn 
expedient  of  treating  symptoms  as  they  arise. 

Attempts  to  stem  the  intestinal  flux  by  astringents  are,  at  this 
stage  of  the  disease,  useless ;  their  powers  are  rendered  abortive  by 
the  rapidity  with  which  they  are  hurried  along  the  canal.  In  fact, 
purgatives  have  more  advocates  than  astringents  at  this  phase  of 
cholera.  Dr.  George  Johnson  endeavoured  to  place  the  purgative 
plan  of  treatment  on  a  scientific  basis,  and  administered  moderate 
doses  of  castor  oil  frequently  repeated.  The  rationale  of  this 
treatment  is  that  the  cholera  poison  is  thereby  eliminated  from 
the  intestines  and  nature  is  aided  in  her  attempts  at  so  doing. 
Reasonable  as  this  treatment  might  seem  to  be,  experience  has 
declared  against  it.  There  is  the  danger  of  the  purgative  continuing 
the  purgation  at  a  period  of  possibly  natural  abatement  of  the 
disease,  when  rest  and  quiet  to  the  intestines  and  the  body  is  of  vital 
consequence.     Rest  in  bed,  warmth  with  free  circulation  of  warm 


CHOLEEA  127 

air  is  essential.  Trie  patient  should  not  be  allowed  to  get  up  to 
stool,  nor  sit  up  in  bed  to  drink.  Ice  to  suck,  or,  in  its  absence, 
hot  (not  cold)  water  to  drink  should  be  freely  supplied,  and  will  help  to 
allay  thirst  and  vomiting.  A  mustard  plaster  to  the  pit  of  the  stomach 
and  hypodermic  injections  of  morpliia  with  atropine  will  tend  to 
allay  vomiting  and  relieve  epigastric  pain  and  restlessness.  Cramps 
are  to  be  relieved  by  firm  rubbing  by  the  hands,  and  cardiac  weak- 
ness by  hypodermic  injections  of  ether  or  digitalin.  Placing  the 
patient  in  a  recumbent  position  in  a  warm  bath  103°  F.  is  an 
excellent  form  of  treatment ;  and  may  be  supplemented  by  injecting 
ice-cold  water  into  the  rectum  whilst  the  patient  is  immersed  in 
the  hot  water.  Slow  intravenous  injection  of  a  saline  fluid  con- 
sisting of  60  grains  of  common  salt  and  an  equal  quantity  of 
carbonate  of  soda,  dissolved  in  a  quart  of  boiled  water  at  a 
temperature  of  100°,  103°,  or  even  105°  F.  has  been  administered 
with  advantage.  Of  other  methods  the  wet  sheet,  spinal  ice-bags, 
intraperitoneal  injections  of  warm  water  and  hot-air  baths,  have 
perhaps  most  to  recommend  them. 

Suppression  of  urine  must  be  treated  by  dry  cupping  over  the 
kidneys,  or  by  poultices  or  hot  fomentations  round  the  waist ; 
intestinal  irritabiUty  may  be  counteracted  by  bismuth  and  opium, 
and  by  the  wet  pack  to  the  abdomen. 

All  food  should  be  withheld  during  the  stage  of  vomiting  and 
purging,  and,  should  the  stage  of  collapse  supervene,  food  given  by 
the  mouth  can  do  nothing  but  harm.  Stimulants,  champagne 
especially,  are  indicated. 

When  the  stage  of  reaction  sets  in,  hastiness  in  administering 
"  nourishing  "  foods  is  to  be  condemned.  Milk-whey,  white-wine 
whey  or  koumiss  should  be  given  in  teaspoonful  doses  at  frequent 
intervals,  every  few  minutes  in  fact.  Freshly-made  tea,  with  or 
without  a  small  quantity  of  whisky  or  brandy,  sipped  slowly  and 
either  warm  or  iced,  is  grateful  to  the  patient.  Rice  tea  (boiling 
water  poured  over  rice  roasted  brown)  is  a  pleasant  and  nourishing 
drink  with  or  without  lemon.  Soon  more  substantial  food  is  wanted. 
Starchy  foods  are  to  be  avoided  and  a  meat  diet  commenced  at 
first.  Raw  meat  juice,  scraped  beef,  plain  jellies,  etc.,  are  to  be 
given  in  small,  even  minute  quantities,  and  frequently  repeated.  In 
a  day  or  two,  finely- minced  beef  hastily  and  very  lightly  cooked 
*  may  be  relished.  Of  starchy  foods,  well-boiled  rice  is  the  first  to 
be  given,  and  then  bread  which  has  been  well  baked. 

James  Cantlie. 


128  MANUAL  OF  MEDICINE 


PLAGUE 

The  term  plague  was  employed  in  ancient,  and  up  to  quite 
modern  times  to  signify  the  prevalence  of  any  epidemic  disease 
attended  by  a  high  rate  of  mortality.  The  word  is  now,  however, 
no  longer  used  in  a  general  sense,  but  as  the  name  of  a  definite 
disease  bearing  specific  characters.  There  is  in  consequence  con- 
siderable confusion  in  determining  the  accurate  history  of  the  actual 
disease,  as  many  ancient  and  mediaeval  writers  employed  it  indis- 
criminately. The  "black  death"  which  devastated  Europe  in  the 
fourteenth  century,  and  the  "great  plague"  which  raged  in  London 
in  1665,  were  without  doubt  plague  as  it  is  now  understood. 

Plague  is  a  specific,  acute,  contagious  disease,  appearing  in 
epidemic  form,  attended  by  a  high  mortality  and  with  a  tendency 
to  linger  and  recur  once  it  has  attacked  a  community.  It  is 
characterised  by  a  febrile  state,  by  the  development  of  buboes  in 
the  deep  and  superficial  glands,  and  by  changes  in  the  lungs, 
spleen,  and  other  organs.  A  specific  diplococcus  is  met  with  in 
the  blood,  excretions  and  viscera  of  persons  suffering  from,  or  who 
have  died  of  plague. 

Geographical  Distribution. — During  the  latter  half  of  the 
nineteenth  century  plague  has  been  met  with  in  Europe,  Asia,  and 
Africa.  In  1853,  and  again  in  1873  ^^^  1897,  plague  existed  in 
Western  Arabia;  in  1858  and  in  1874  it  appeared  in  Tripoli;  the 
northern  part  of  Persia  was  severely  visited  in  1863,  and  again 
in  1870.  Mesopotamia  from  1874-1877  proved  the  centre  of  a 
widespread  epidemic  which  reached  nortliwards  to  the  Caspian 
shores,  advanced  up  the  Volga  in  1878,  and  extended  westwards 
as  far  as  Syria  and  eastward  to  Persia. 

Since  plague  appeared  in  South-Eastern  China  in  1894,  it  has 
been  met  with  in  Formosa,  Annam,  and  the  Bombay  Presidency  as 
a  severe  epidemic  ;  in  Southern  India,  Calcutta,  on  the  shores  of 
the  Persian  Gulf,  at  the  port  of  Mecca,  in  the  islands  of  Mauritius, 
Reunion,  Madagascar,  and  Penang,  and  in  the  towns  of  Alexandria 
and  Oporto  it  existed  in  a  mild  form  during  1 898-1 899.  Koch? 
has  demonstrated  the  presence  of  plague  in  the  districts  of  Bukoba 
and  Kitengule  in  German  East  Africa;  and  from  the  hinterland  of 
the  French  possessions  in  West  Africa  plague  was  reported  during 


PLAGUE  129 

1899.  The  malady  first  reached  the  American  continent  in  1899, 
appearing  at  Santos,  a  seaport  town  of  Brazil. 

The  disease  has  been  long  known  as  Mdhdmari  in  the  districts 
of  Kumaon  and  Ghurwal  in  the  north-west  provinces  of  India  3  and 
in  the  Chinese  provinces  of  Sze-chuen  and  Yunnan  on  the  borders 
of  Thibet  many  writers  have  described  it  under  the  name  of 
"Yunnan"  plague.  Hence  Kumaon  and  Ghurwal  in  India,  and 
Sze-chuen  and  Yunnan  in  China,  are  held  by  many  to  be  the  endemic 
seats  o^  ])lague. 

Etiology. — Plague  is  held  to  be  one  of  the  "filth"  diseases, 
and  it  attacks  principally  the  least  sanitary  parts  of  every  city.  In 
proportion  to  the  extent  of  insanitation,  so  does  the  severity  of  the 
outbreak  vary.  Infants  and  aged  persons  are  less  likely  to  contract 
plague  than  are  the  others  of  the  community,  but  sex  seems  to  be  no 
protection.  Plague  prevails  as  a  rule  during  the  cool  weather  in 
tropical  countries,  great  heat  causing  a  subsidence  in  its  virulence. 
In  contradistinction  to  this  general  rule  there  are  several  exceptions, 
for  in  Hong-Kong  and  Poona  in  1899  plague  was  at  its  maximum 
during  the  hottest  part  of  the  summer.  Europeans  dwelling  in  close 
proximity  to  plague-stricken  areas  in  Asia,  suffer  or  escape  in  pro- 
portion as  they  live  after  the  manner  of  the  natives,  or  in  the  more 
sanitary  state  of  Western  Europe. 

Bacteriology. — In  1894,  during  the  epidemic  of  plague  in 
Hong-Kong,  Professor  Kitasato  of  Japan  discovered  the  plague 
microbe,  and  since  then  the  presence  of  the  organism  has  been 
noted  in  the  blood,  secretions,  and  organs  of  persons  suffering 
from  plague  wherever  the  disease  has  prevailed.  Experimental 
investigations  show  that  the  disease  can  be  communicated  to 
several  of  the  lower  animals,  and  all  observation  goes  to  show  that 
the  bacterium  known  as  the  plague  bacillus  (Kitasato)  is  the  cause 
of  the  disease. 

Simultaneously  with,  if  not  antecedent  to,  an  outbreak  of  plague 
rats  are  attacked  by  all  the  symptoms  of  plague,  and  die  in  great 
numbers.  Other  animals  may  also  be  attacked,  but  none  are  so 
prominently  or  so  constantly  affected. 

The  bacillus  of  plague  has  been  found  in  the  dust  and  filth  of 
infected  houses,  but  the  exact  relation  of  the  disease  to  the  soil,  if 
indeed  the  soil  bears  any  part  in  the  life-history  of  the  parasite, 
has  not  been  ascertained.  Certain  it  is,  however,  that  the  bacillus 
thrives  better  in  some  localities  than  in  others,  where  there  is  but 
little  difference  in  latitude  or  sanitation.  This  is  well  instanced  in 
the  cases  of  Bombay  and  Calcutta.  In  the  former,  plague  at  once 
VOL.  I  K 


I30  MANUAL  OF  MEDICINE 

became  severely  epidemic,  whilst  in  Calcutta  the  disease  for  several 
years  appeared  in  a  mild,  almost  a  sporadic  form. 

The  microbe  of  plague  is  met  with  in  the  fluids  which  surround 
an  inflamed  gland,  in  the  gland  itself,  and  in  the  pus  from  a  newly- 
opened  bubo.  The  bacillus  is  also  found  in  the  spleen,  lungs, 
liver,  kidneys,  stomach,  and  intestinal  walls.  In  the  saliva,  the 
expectoration,  the  faeces,  and  the  urine  the  micro-organism  has 
been  shown  to  exist.  In  the  blood  the  bacillus  is  easily  demon- 
strated in  the  later  stages  of  fatal  cases,  but  frequently  it  is  only  to  be 
found  in  infinitesimal  numbers  in  the  earlier  stages  of  the  disease. 

The  plague  bacillus  is  readily  stained  by  all  basic  aniline  dyes,  when 
it  is  to  be  seen  as  a  short  flagellated  rod  with  rounded  ends  measuring 
I  yu,  in  length  and  0.3  /x  in  breadth  (Plate  I.).  At  each  end  the  bacillus 
stains  more  deeply  than  in  the  centre,  and  sometimes  a  clear  area  round 
the  bacillus  can  be  seen.  In  stained  cover-glass  preparations  the  bacillus 
resembles  a  diplococcus,  but  occasionally  four  to  six  of  the  bacilli  in 
culture  preparations  are  seen  to  form  a  chain  simulating  streptococci. 
The  microbe  does  not  sporulate  ;  in  fresh  specimens  it  is  seen  to  be 
motile.  The  best  culture  medium  is  one  composed  of  "a  2  per  cent 
alkaline  solution  of  peptone  containing  i  per  cent  gelatine "  (Wilm). 
A  temperature  between  36°  C.  and  39°  C.  is  the  most  favourable  for  the 
growth  of  the  bacillus.  At  a  temperature  below  25°  C.  and  above  40°  C. 
a  decline  in  the  rapidity  of  the  growth  becomes  apparent.  "  On  gelatine 
plates  the  bacillus  grows  without  liquefying  the  medium,  and  produces 
in  forty-eight  hours  small,  round,  grayish-white  colonies  "  (Wilm).  On 
bouillon  the  growth  of  the  bacillus  forms  at  the  bottom  and  along  the 
sides  of  the  test-tube  as  a  granular  or  flocculent  precipitate,  whilst  the 
bouillon  itself  remains  clear.  When  the  tube  is  shaken  the  precipitate 
is  distributed  through  the  fluid.  On  potato,  at  blood-heat,  a  very  delicate, 
scanty,  grayish-white  or  white  crusted  growth  is  formed  after  thirty-six 
hours.  On  agar  plates  two  forms  of  colonies  are  met  with,  a  large 
and  small,  and,  when  puncture  cultivations  in  agar  tubes  are  made,  the 
seed  from  the  smaller  colonies  shows  a  scantier  growth  than  that  from 
the  larger.  This  variability  of  the  plague  organism  in  regard  to  growth 
is  borne  out  experimentally  in  regard  to  its  toxic  power. 

CorainumcabLlity. — Plague  can  be  carried  by  persons  or 
animals  suffering  from  plague,  and  by  articles  of  clothing,  food,  or 
water  which  have  become  contaminated.  Although  the  disease  is 
to  some  extent  transmissible,  it  appears  that,  with  ordinary  care, 
there  is  no  great  danger  of  contracting  it.  It  is  seldom  that  either 
doctors,  nurses,  or  sick  attendants  are  attacked  through  attend- 
ance at  plague  hospitals,  provided  precautions  are  taken,  such  as 


PLAGUE  131 

sleeping  in  good  quarters,  taking  meals  away  from  the  hospital,  etc., 
etc.  The  disease  is,  however,  certainly  contagious  and  inoculable. 
A  nursing  sister  in  Hong-Kong  who  had  been  through  two  epidemics 
of  plague  succumbed  to  the  disease  brought  on  by  receiving  the 
expectoration  of  a  delirious  patient  on  her  conjunctiva.  Two  of  the 
Japanese  physicians,  studying  plague  in  Hong-Kong  in  1894,  were 
inoculated  at  a  post-mortem  examination,  and  suffered  severely. 
Animals,  such  as  cattle,  pigs,  dogs,  and  especially  rats  and  mice, 
contract  plague,  and,  possibly  by  their,  contaminating  human  food, 
become  a  source  of  infection.  This  fact  accounts,  no  doubt,  for 
the  belief  that  grain  is  a  source  of  infection.  Food  may  also  be 
rendered  infectious  by  flies.  The  clothes  of  persons  suffering 
from  plague  harbour  the  virus,  as  shown  by  Wilm,  who  succeeded 
in  cultivating  the  bacillus  from  portions  of  clothing  that  had  been 
soiled  by  the  urine  or  fgeces  of  plague  patients.  The  water  of 
various  wells  was  found  to  contain  the  plague  bacillus  in  Hong- 
Kong  during  1896.  The  plague  bacillus  may  enter  the  body  by 
the  skin.  This  belief  was  surmised  owing  to  the  frequency  with 
which  the  bare-footed  coolies  in  China  showed  groin  buboes.  There 
is  reason  to  believe  that  flies  and  fleas  may  communicate  the  disease. 
It  is  presumed  that  the  virus  can  be  inhaled,  owing  to  the  frequency 
with  which  primary  pneumonia  appears  during  some  outbreaks.  The 
bacillus  may  also  enter  the  body  by  the  alimentary  canal.  This  is 
known  to  be  the  case  as  the  result  of  feeding  animals  with  cultures 
or  infected  food. 

Incubation. —  From  three  to  five  days  is  the  usual  period  of  in- 
cubation. Statements  that  incubation  may  vary  from  a  few  hours 
to  eight  days,  or  even  longer,  are  probably  to  be  explained  by  the 
source  of  infection  having  been  mistaken. 

Symptoms. — Frodrojnal  sympto?ns  are  seldom  observed,  but 
for  a  day  or  so  before  the  disease  sets  in,  lassitude,  loss  of  appetite, 
and  pain  in  the  loins  have  been  recorded. 

Livasmi. — The  symptoms  of  plague  are  generally  ushered  in 
suddenly  by  a  rigor  accompanied  by  a  hot  and  dry  skin,  headache, 
and  marked  prostration.  The  face  is  dusky,  the  eyes  sunken,  the 
features  drawn,  and  the  expression  vacant.  Mental  ineptitude  is 
shown  from  almost  the  first  onset  of  the  disease.  Fever  is  a  con- 
stant symptom  in  all  cases  of  plague.  In  a  certain  proportion  the 
temperature  runs  up  in  an  hour  or  two  to  104°  F.  or  higher,  but  the 
maximum  is  usually  attained  on  the  third  or  fourth  day,  when  the 
thermometer  registers  frequently  106"  F.  or  over.  Very  high 
temperatures  are  not,  however,  by  any  means  constant  \  the  thermo- 


132  MANUAL  OF  MEDiCINE 

meter  may  never  register  over  loi"  F.  After  a  sudden  initial  rise 
the  temperature  in  a  day  or  two  may  fall  below  normal ;  on  the 
other  hand,  it  may  remain  high  till  death  occurs,  or  in  cases  of 
recovery  fever  may  continue  for  weeks.  Curiously  enough  the  pre- 
sence or  absence  of  high  fever  gives  no  guide  to  the  chance  of 
recovery,  as  many  patients  in  whom  the  temperature  fell  to  the 
,  normal  after  a  day  or  two  succumbed,  or,  on  the  other  hand,  re- 
!  covered  as  readily  as  those  in  whom  the  fever  continued  high. 

Variations  in  Type. — Several  terms  are  employed  to  denote 
varieties  in  the  signs  and  symptoms  of  plague  :  bubonic,  intestinal, 
pneumonic,  convulsive,  toxic,  typhus  type,  pestis  siderans,  pestis 
ambulans,  pestis  minor.  These  terms,  for  the  most  part,  explain 
themselves.  The  viscus  indicated  may  alone  show  signs  and 
symptoms  of  being  affected.  A  toxic  form  implies  that  the  symp- 
toms resemble  a  septicaemia,  no  local  signs  developing.  Siderans 
indicates  a  rapidly  fatal  form,  and  ambulans  a  mild  type,  during 
which  the  patient  may  not  even  be  confined  to  bed.  The  last 
mentioned  however,  pestis  minor,  may  be,  and  probably  is,  a  disease 
quite  apart.  It  consists  of  a  prevalence  of  non- venereal  buboes 
which,  although  noted  during,  before,  or  after  epidemics  of  plague, 
may  exist  independently  of  the  more  severe  illness. 

The  Lymphatic  System. — Although  plague  is  frequently  termed 
"bubonic  plague,"  buboes  are  by  no  means  invariably  present.  In 
73  per  cent  of  the  cases,  however,  they  are  readily  detected  in 
one  or  more  parts  of  the  body  in  almost  every  epidemic.  Visible 
swelling  of  the  glands  may  usher  in  the  disease,  may  appear  during 
the  first  twenty-four  hours,  may  defer  its  appearance  until  the  fifth 
day,  or  may  never  become  evident.  The  groups  of  glands  attacked 
in  order  of  frequency  are,  the  inguinal  (vertical  and  oblique),  the 
axillary,  and  the  cervical ;  internal  glands  are  also  frequently  involved. 
Buboes  develop  with  amazing  rapidity;  in  a  few  hours  they 
may  increase  from  the  size  of  a  hazel  nut  to  a  pigeon's  egg,  and  in 
the  course  of  a  day  or  two  become  as  large  as  an  orange.  The 
inflammation  extends  rapidly  to  the  periglandular  tissues,  causing 
oedema,  subcutaneous  hemorrhage,  and  finally  suppuration  of  the 
tissues  around.  The  skin  becomes  raised,  red  and  oedematous  ;  the 
subcutaneous  tissues  become  infiltrated,  widely  obscure  the  glandular 
swelling  and  cause  extensive  discoloration  and  induration.  If  the 
gland  is  deep-seated,  pain  is  seldom  complained  of,  unless  firmly 
pressed  upon  ;  but  the  patient  maintains  the  limb  in  that  position 
best  calculated  to  relieve  tension.  In  90  per  cent  the  buboes  sup- 
purate, the  result  of  a  mixed  infection  with  pyogenetic  organisms ; 


PLAGUE  133 

the  skin  dies,  and  a  slough,  several  inches  in  diameter,  separates, 
exposing  a  deep,  rugged  cavity,  discharging  pus,  and  presenting  in 
many  instances  the  necrosed  gland  at  the  bottom  of  the  space.  As 
a  rule  sloughing  of  the  cutaneous  structures  takes  place  from  the 
tenth  to  the  fourteenth  day.  Buboes  which  do  not  suppurate  retain 
a  well-marked  induration  for  some  time  and  disappear  slowly.  The 
presence  or  absence  of  buboes  in  no  way  affects  the  mortality. 

Digestive  system. — It  would  seem  that  in  a  certain  proportion  of 
cases  the  gastro-intestinal  tract  is  the  seat  of  acute  and  primary 
symptoms,  more  especially  in  instances  in  which  buboes  are  not  a 
prominent  feature.  The  lips  become  speedily  dry  and  cracked  ;  the 
tongue  is  at  6rst  red  at  tip  and  edges,  and  covered  on  the  dorsum 
by  a  fur  which  changes  from  a  grayish-white  to  a  mahogany-brown 
or  even  black  crust.  The  tongue  appears  swollen  and  indented  or 
shrivelled  and  fissured.  The  mucous  membrane  of  the  mouth 
and  fauces  are  unnaturally  dry  and  redder  than  usual,  there  is 
great  thirst  at  the  onset,  loss  of  appetite,  and  at  times  persistent 
vomiting  of  a  watery,  bilious,  or  coffee-ground  fluid.  The  bowels 
during  the  acute  illness  are  usually  constipated,  the  faeces  being 
hard,  dark  yellow  or  brown  in  colour,  and  later,  loose  dejections  of 
a  mustard  colour  occur,  with  occasionally  blood  and  mucus  in  the 
stools. 

The  liver  is  often  enlarged,  and  the  spleen  always  so.  It  is 
seldom  that  pain  can  be  elicited  over  either  by  percussion  or 
palpation. 

The  respiratory  tract. — Although  a  pneumonic  variety  of  plague 
prevails,  more  especially  during  certain  epidemics,  the  lungs  in  the 
ordinary  type  of  plague  show  but  few  symptoms  of  being  affected. 
Evanescent  patches  of  congestion  occur,  which  seem  to  come 
and  go  according  to  the  position  of  the  patient.  In  some  10  per 
cent  of  cases  a  bronchial  catarrh  supervenes  and  occasionally  the 
sputum  is  bloody.  The  purely  pneumonic  type  is  characterised  by 
the  usual  signs  and  symptoms  of  lobar  pneumonia  and  is  exceed- 
ingly fatal. 

The  heart  and  circulation. — The  pulse  at  the  commencement  of 
the  illness  is  full  and  tense  as  a  rule,  and  at  times  irregular.  As  the 
strength  fails  the  pulse  becomes  quick  (140),  feeble,  and  fluttering. 
Percussion  frequently  reveals  the  right  side  of  the  heart  to  be  dilated, 
and  systolic  cardiac  murmurs  over  the  apex  may  be  said  to  be 
common.     With  these  exceptions  heart  lesions  are  extremely  rare. 

HcE-morrhages  from  one  or  other  of  the  mucous  surfaces,  or  into 
the  skin,  are  common,  and  may  appear  early  in  the  disease. 


134  MANUAL  OF  MEDICINE 

The  urinary  system. — The  urine,  during  some  of  the  recorded 
epidemics,  remains,  as  a  rule,  unaltered,  but  in  others  marked 
abnormalities  are  met  with.  During  the  1896  recrudescence  in 
Hong-Kong,  Wilm  states  that,  in  95  per  cent  of  the  cases,  the  urine 
at  the  outset  of  the  disease  contained  albumen,  and  in  many 
instances  indican.  Suppression  of  urine  is  a  frequently  observed 
condition  at  the  commencement  of  the  illness,  but  with  the  decline 
of  the  fever,  the  quantity  becomes  normal  and  the  albumen  dis- 
appears, although,  on  the  other  hand,  albumen  has  continued  to 
appear  in  the  urine  for  months  subsequently.  Granular  casts  and 
red  blood  corpuscles  are  frequently  found  microscopically. 

The  nervous  system. — Plague  is  associated  with  a  peculiar  mental 
state.  When  first  seized  the  patient  may  become  wildly  delirious. 
The  usual  form  it  takes  is  that  he  rushes  from  his  room  to  the 
verandah,  or  into  the  street,  but  the  will  power  soon  falls  into 
abeyance  and  he  can  assign  no  reason  for  his  act  when  interrogated. 
Instead  of  furious  deUrium,  or  subsequent  to  it,  the  patient  may  be 
apathetic,  hstless,  and  but  semi-conscious  of  what  is  said  to  him  or 
what  goes  on  around  him.  His  features  become  expressionless,  and 
when  spoken  to  he  turns  towards  the  speaker  with  a  dazed  look,  his 
gaze  resting  for  a  moment,  and  then  by  feature,  voice,  or  movement 
it  is  apparent  he  is  but  semi-conscious.  In  children  muscular 
twitchings  and  convulsions  are  frequently  seen. 

Convalescence. — A  slow  recovery  is  the  rule  after  plague.  It  is 
usually  two  or  three  months  before  the  patient's  strength  is  fairly 
restored.  Relapses  of  the  nature  of  fresh  adenitis,  carbuncles, 
abscesses,  pneumonia,  nephritis,  meningitis,  keratitis,  and  various 
forms  of  paresis,  although  seldom  fatal,  delay  complete  recovery. 

Recurrence. — There  are  but  few  examples  of  recurrence.  In  the 
experience  of  the  writer  but  one  case  is  known.  A  nursing  sister  in 
Hong-Kong  recovered  from  a  severe  attack  of  plague  in  Hong-Kong. 
Two  years  after  she  had  a  second  attack,  from  which  she  also 
recovered. 

Diagnosis. — When,  during  an  epidemic  of  plague,  a  patient  is 
found  with  fever,  a  dazed  appearance,  a  furred  tongue,  when  he 
maintains  his  limbs  in  a  position  to  afford  relief  from  pain,  and  when 
in  the  groins,  axilla,  or  neck  enlarged  and  tender  glands  are  found, 
a  diagnosis  of  plague  may  be  made.  Mistakes  are,  however,  possible, 
although  not  frequent.  One  of  the  most  marked  occurred  to  the 
writer.  During  the  1894  epidemic  in  Hong-Kong  the  writer  was 
called  to  see  a  Parsee  who  had  high  fever,  great  thirst,  a  coated 
tongue,  vomiting,  and  enlarged  and  tender  groin  glands.    A  diagnosis 


PLAGUE  135 

of  plague  was  made,  the  conclusion  being  no  doubt  contributed  to 
by  the  fact  that  on  the  previous  day  a  Parsee  had  died  of  plague  in 
the  same  house.  The  diagnosis,  however,  was  wrong,  as  subsequent 
examination  of  the  man's  blood  showed  that  he  was  the  subject  of 
filaria.  The  only  evidence  to  be  relied  on  is  the  presence  of  the 
plague  bacillus  in  the  blood  or  the  secretions  of  the  patient. 

Morbid  anatomy. — In  bodies  of  persons  dead  of  plague 
rigor  mortis  sets  in  early,  and  is  quite  moderate  in  degree.  The 
skin  occasionally  shows  petechiae,  carbuncles,  and  haemorrhage  into 
the  subcutaneous  tissues. 

The  lymphatic  glands. — Almost  every  lymphatic  gland  in  the 
body  may  be  found  to  be  swollen  and  hyperaemic.  The  most  in- 
tensely affected  glands  are  of  a  deep  violet  colour  throughout,  or 
flecked  by  white  foci  of  purulent  matter.  Around  the  glands  the 
tissues  are  matted  together,  and  a  serous,  sero-sanguineous,  or 
purulent  fluid  extends  widely  at  times  into  the  neighbouring 
structures.  It  is  usual  to  find  chains  of  enlarged  glands  matted 
together,  and  in  the  groin  they  may  be  found  extending  upwards 
beneath  Poupart's  ligament  to  the  iliac  fossa,  and  even  to  the  lumbar 
and  retro-peritoneal  glands  generally.  The  mesenteric  glands  are 
frequently  found  affected,  although  no  lesion  is  to  be  met  with  in  the 
intestine. 

The  heart. — The  pericardium  occasionally  shows  petechial  or 
ecchymosed  spots,  but  the  pericardial  fluid  is  not  abnormal.  The 
heart  muscle,  when  cut  into,  appears  towards  its  inner  aspects  pale 
and  soft,  and  the  fibres  exhibit  a  cloudy  appearance  or  fatty  degenera- 
tion. The  right  side  of  the  heart  and  the  great  venous  trunks  of 
the  thorax  and  abdomen  are  to  be  seen  distended  with  dark  fluid 
blood.  The  lungs. — The  lower  lobes  of  the  lungs  especially  are,  as 
a  rule,  congested  and  oedematous ;  pneumonia  occurs  in  a  certain 
number  of  cases,  and  much  more  in  some  epidemics  than  in  others. 
The  mucous  membrane  of  the  respiratory  tract  seems  affected  by  an 
oedematous  condition  of  the  submucous  coat  with  occasional  petechiae. 
The  pleurae  are  occasionally  ecchymosed,  but  the  pleural  fluid  is 
usually  unaltered  in  quantity  or  consistence.  The  stomach  con- 
tents are  small  in  amount,  and  of  a  dark -brown  colour.  The 
longitudinal  ridges  present  injected  crests  and  a  pale  grayish-white 
colour  in  the  depressions ;  multiple  small  haemorrhages  into  the 
coats  of  the  stomach  are  fairly  constant.  The  intestine  is  usually 
hyperaemic  throughout ;  the  mucous  coat  presents  small  haemorrhages 
and  ecchymosed  spots  ;  the  solitary  glands  are  swollen ;  Peyer's 
patches   are   enlarged   and   raised,  and   are  frequently  the   seat  of 


136  MANUAL  OF  MEDICINE 

haemorrhages  or  ulcers.  The  mesentery  frequently  contains  exten- 
sive extravasation  of  blood  ;  it  is,  in  the  majority  of  cases  (60  per 
cent,  Wilm),  studded  with  enlarged  glands  of  various  sizes  ;  and, 
as  in  other  parts  of  the  body  also,  hcemorrhages  occur  around  the 
glands.  The  intestinal  and  mesenteric  lesions  are  always  most 
marked  in  cases  in  which  external  buboes  are  not  met  with.  The 
liver  is  slightly  enlarged,  firm,  and  on  section  of  a  whitish- pink 
tinge  with,  at  times,  small  hemorrhages  beneath  the  capsule.  The 
gall  bladder  is  fairly  full  in  all  cases,  and  tightly  distended  in 
many  cases.  The  spleen  is  enlarged  to  as  much  as  twice  or  more 
ts  natural  size ;  beneath  the  capsule  haemorrhages  are  common ; 
the  consistency  varies,  being  at  times  firm,  at  other  times  quite  soft 
and  diffluent.  The  kidneys  are  congested ;  the  stellate  vessels  are 
pronounced ;  and  the  parenchyma  is  in  a  state  of  cloudy  swelling. 
Around  the  kidney  the  loose  connective  tissue  is  the  seat  of  large 
extravasations  of  blood  which  frequently  extend  down  into  the  pelvis. 
The  pelvis,  the  ureters,  and  the  bladder  contain  small  coagula  of 
blood.  The  brain. — The  only  changes  met  with  are  occasionally 
cedema  of  the  brain  substance  with  oedema,  congestion,  and  small 
ecchymoses  in  the  pia  mater. 

Prognosis. — The  prognosis  of  bubonic  plague  is  bad  in  the 
extreme ;  neither  age  nor  sex  is  exempt,  nor  do  either  avail  in  pre- 
venting a  fatal  issue. 

Persons  living  in  insanitary  abodes,  where  over-crowding  and 
insufficiency  of  food  prevail,  are  most  liable  to  infection.  Europeans 
in  tropical  countries,  no  doubt  on  account  of  their  superior  housing 
and  mode  of  living  as  compared  with  the  natives,  seem  to  enjoy  a 
certain  immunity.  Race  may  have  something  to  do  with  immunity. 
Of  the  seven  Japanese  doctors  engaged  in  scientific  work  during  the 
plague  in  Hong-Kong  three  contracted  plague,  whilst  of  eleven 
British  doctors  engaged  in  treating  plague  patients  not  one  caught 
the  disease.  In  Egypt  (1899),  however,  the  residents  of  European 
extraction  seemed  as  liable  to  the  disease  as  the  native  Egyptian. 
This  is  due  in  all  probability  to  the  fact  that  many  of  the  former 
live  after  the  manner  of  the  native  Egyptians. 

A  bad  prognosis  is  indicated  when  high  fever  appears  early, 
when  severe  epigastric  pain  and  vomiting  prevail,  when  the  urine  is 
suppressed,  and  when  buboes  rapidly  develop  with  extensive  sub- 
cutaneous haemorrhage.  A  better  prognosis  is  justifiable  when  the 
initial  temperature  rises  gradually,  when  buboes  but  slightly  or  very 
gradually  develop,  when  the  patient  survives  the  sixth  day,  and  when 
the  urinary  secretion  remains  normal. 


PLAGUE  137 

Mortality.  —  The  death-rate  amongst  the  Chinese,  treated 
according  to  native  fashion,  numbered  about  95  per  cent  (1884). 
In  European  hospitals  the  mortality  was  less  by  some  15  per  cent. 
Death  in  70  per  cent  of  the  cases  occurs  during  the  first  six  days  of 
the  illness,  but  it  may  be  delayed  to  the  second,  third,  or,  in  rare 
cases,  to  the  fifth  week. 

Europeans  stand  a  better  chance  of  recovery,  some  50  per  cent 
only  of  those  attacked  dying.  Death  may  suddenly  occur  any  time 
after  the  onset;  convulsions  or  a  comatose  state  may  supervene  early 
in  the  disease:  or,  with  signs  of  deep  nervous  depression,  the  patient 
collapses.  Later,  death  seems  to  result  from  exhaustion,  the  result 
of  a  pysemic  condition. 

Prophylaxis. ^ — Seeing  that  rats  and  mice  are  the  animals  which 
convey  plague,  and  by  which  human  beings  become  affected,  their 
destruction  before  a  threatened  invasion  of  plague  is  an  absolute 
necessity  if  the  disease  is  to  be  averted.  Should,  however,  plague 
develop  it  is  necessary  to  isolate  the  sick,  segregate  those  who  have 
lived  with  or  near  them,  and  thoroughly  disinfect  or  destroy  their 
houses,  furniture,  and  clothing,  whilst  at  the  same  time  war  is  still 
waged  against  the  rat.  Special  prophylaxis  may  be  obtained  by  in- 
pculation  with  one  of  the  several  "sera"  prepared  for  the  purpose. 
Of  these  Haffkine's  is  the  one  which  seems  to  have  stood  a  practical 
test.  Haffkine  found  different  media  to  afford  rich  cultures  of 
plague  bacilli.  The  virulence  of  these  was  such  that  one  or  two 
minims  were  sufficient  to  kill  the  largest  rodents.  To  lessen  the 
virulence  Haffkine  resorted  to  destruction  of  the  bacilli  by  heat, 
but  the  liquid  thus  deprived  of  its  bacilli  proved  to  possess  but 
slight  powers. 

"  In  order  to  accumulate  for  the  plague  prophylactic  a  large 
amount  of  extra-cellular  toxins,  the  baciUi  are  cultivated  on  the 
surface  of  a  liquid  medium,  where  they  are  suspended  by  means  of 
drops  of  clarified  butter  or  of  cocoa-nut  oil.  The  bacilli  grow  down 
in  long  threads  into  the  depth  of  the  liquid,  and  produce  what  we 
have  termed  a  stalactite  growth  in  broth,  an  appearance  singularly 
peculiar  to  this  microbe,  and  which,  I  hope,  will  be,  till  further  dis- 
covery, accepted  as  the  exclusive  diagnostic  feature  of  this  microbe. 
The  products  of  their  vital  exchanges — the  toxins — are  secreted  by 
the  stalactites  into  the  liquid  and  accumulated  there.  The  growth 
is  periodically  shaken  off  the  drops  of  oil,  after  which  a  new  crop 
appears  underneath  the  surface  of  the  liquid "  (Haffkine  on  Pre- 
ventive Inoculation).  In  this  manner  the  bodies  of  the  microbes 
collect    at    the    bottom    of  the  cultivation  vessel,  and    the    liquid 


138  MANUAL  OF  MEDICINE 

around  becomes  permeated  with  toxins.  The  process  is  kept  up 
for  five  or  six  weeks,  when  "  the  bodies  of  the  microbes  become 
extremely  deteriorated."  In  order  to  render  harmless  the  inocula- 
tion of  the  virus  thus  prepared,  Haffkine  determined  to  kill  the 
microbes  by  heating  the  whole  up  to  65°  or  70°  C. 

The  minimising  effect  of  the  prophylactic  thus  prepared  by 
Haffkine  was  first  tested  on  rabbits,  and  its  powers  of  protection 
proved.  Then  the  perfect  harmlessness  of  the  inoculation  was 
demonstrated  on  Haffkine  himself  and  a  number  of  Europeans  in 
Bombay  who  submitted  to  the  inoculation.  Many  thousands  of 
persons  have  been  "protected"  by  this  prophylactic,  and  the  ques- 
tion now  is  not  does  the  fluid  procure  immunity,  but  only  how  long 
does  the  conferred  immunity  last.  As  a  temporary  expedient  the 
Government  of  India  grant  certificates  entitling  inoculated  persons 
to  exemption  from  plague  rules  for  six  months.  In  all  probability 
this  time  will  be  extended  as  experience  aids  theory  in  the  matter. 

The  dose  of  prophylactic  administered  is  usually  three  cubic 
centimetres.  The  operation  is  followed  by  slight  fever,  with  head- 
ache, nausea,  loss  of  appetite,  lassitude,  and  swelling  at  the  seat 
of  puncture.  In  two  to  three  days  all  feeling  of  discomfort 
subsides. 

Treatment. — In  plague,  perhaps  more  than  any  other  disease, 
symptoms  have  to  be  treated  as  they  arise.  Calomel  in  lo-grain 
doses,  followed  by  a  saline  purge,  may  be  given  in  the  initial  stages. 
The  rationale  of  this  treatment  is  founded  upon  the  fact  that 
constipation  usually  prevails,  that  the  conjunctivae  are  yellow,  the 
gall  bladder  full,  and  that  the  bacilli  are  naturally  eliminated  by  the 
bowel.  Instead  of  calomel  a  continued  action  of  the  bowels  may 
be  kept  up  by  2-drachm  doses  of  sulphate  of  magnesium  twice  or 
thrice  daily.  When,  in  the  later  stages,  diarrhoea  occurs,  appropriate 
remedies  are  demanded  should  it  prove  excessive.  High  tempera- 
ture is  best  combated  by  phenacetin  in  5  to  i  o-grain  doses,  repeated 
as  required,  and  by  the  wet  pack.  To  calm  the  delirium,  an  ice-bag 
to  the  head  is  to  be  applied,  and  narcotics  employed.  Of  these 
morphia  (gr.  ^),  hyoscine  (j-g-oth  gr.),  may  be  administered  hypo- 
dermically,  or  bromides  given  internally.  The  practitioner,  however, 
must  devote  his  attention  to  combating  heart  failure ;  alcohol, 
ammonia,  with  or  without  digitalis,  strychnine,  hypodermics  of  ether 
and  camphor  are  the  cardiac  stimulants  mostly  in  vogue.  Carbonate 
of  ammonia  in  5 -grain  doses,  combined  with  decoct:  cinchonse 
CO.  §1  every  four  hours  is  a  convenient  formula,  the  more  specific 
drugs   being   administered   when    urgent    symptoms    arise.      When 


RELAPSING  FEVER  139 

pneumonia  or  bronchitis  is  present  expectorant  remedies  are  to  be 
employed.     Two-grain  doses  of  carbolic  acid  are  recommended. 

Gland  swellings  are  dealt  with  according  to  their  stage  of  develop- 
ment. When  just  formed  glycerine  and  belladonna  is  a  favourite 
application,  and  liniment  of  iodine  may  be  painted  on  the  skin  over 
the  bubo,  or  the  substance  of  the  gland  is  injected  with  pure  carbolic 
acid,  or  a  preparation  of  corrosive  sublimate  and  iodide  of  potassium. 
When  the  glands  soften  and  threaten  to  suppurate  wet  compresses 
or  poultices  are  applied  in  a  conventional  way ;  but,  finally,  the 
abscess  has  to  be  opened,  the  gland  removed,  and  the  abscess  cavity 
packed  with  antiseptic  dressing. 

Yersin  introduced  a  curative  preparation  derived  from  the  serum 
of  horses.  Successive  horses  were  inoculated,  and  the  potency  of 
the  fluid  reduced  to  a  form  in  which  it  could  be  safely  introduced 
into  the  human  body.  The  Pasteur  Institute  in  Paris  has  elaborated 
Yersin's  method,  and  the  report  of  Professor  Calmette  as  to  the 
efficacy  of  this  preparation  in  Oporto  is  most  encouraging. 

Quarantine. — The  ordinary  rules  of  quarantine  are  applicable 
in  plague.  It  seems  to  be  based  on  sufficiently  widespread  observa- 
tion that  incubation  is  a  matter  of  five  days,  and  that  in  the  cargo 
of  ships  the  bacillus  can  survive  for  a  few  days  only.  An  individual 
who  has  recovered  is  considered  as  being  capable  of  communicating 
the  disease  for  three  weeks  after  the  subsidence  of  the  acute  symp- 
toms, and  isolation  of  the  patient  should  be  maintained  for  at  least 
a  month. 

James  Cantlie. 


RELAPSING    FEVER 

Syn.  Famine  Fever 

Relapsing  fever  is  an  infectious  disease  caused  by  the  presence 
of  a  micro-organism — the  Spirillum  Obermeieri — in  the  blood. 
Epidemics  were  frequent  in  Ireland  and  Scotland  during  the  early 
part  of  the  century ;  of  late  years  the  disease  has  rarely  appeared 
in  the  United  Kingdom.  The  poor  and  destitute  are  the  principal 
sufferers,  and,  like  typhus  fever,  epidemics  have  been  most  prevalent 
during  times  of  famine.  The  majority  of  cases  occur  in  patients 
between  the  ages  of  fifteen  and  twenty ;  children  under  five  years 


I40  MANUAL   OF   MEDICINE 

of  age  are  rarely  attacked.  One  attack  confers  a  very  limited  pro- 
tection against  future  invasion.  The  contagion  is  usually  conveyed 
directly  from  patient  to  patient,  less  frequently  by  means  of 
fomites. 

Period  of  incubation. — The  incubation  period  varies  between 
one  and  twenty-one  days.  In  monkeys  the  first  symptoms  appear 
from  thirty  hours  to  five  days  after  inoculation. 

Clinical  course  and  symptoms.  —  The  disease  takes  a 
characteristic  course,  divided  into  the  following  stages  : — An  attack 
of  fever  lasting  a  week  or  thereabouts ;  an  intermission  of  about  a 
week,  during  which  the  patient  is  free  from  symptoms ;  a  second 
attack  of  fever,  the  relapse,  of  some  three  days'  duration. 

The  attack  begins  suddenly  with  a  rigor  or  shivering,  the 
temperature  quickly  running  up  to  between  102"  and  106'  F.  With 
the  rise  of  temperature  the  usual  symptoms  of  fever  supervene,  thirst, 
headache,  loss  of  appetite,  etc.  Severe  pains  in  the  back  and  limbs 
are  often  prominent  symptoms.  In  spite  of  the  high  temperature, 
delirium  and  other  mental  disturbances  are  uncommon.  The  skin 
becomes  of  a  yellow  tint,  and  there  may  be  distinct  jaundice,  with 
bile  in  the  urine,  the  stools  being  of  normal  colour.  The  liver  and 
spleen,  especially  the  latter,  become  enlarged  and  tender.  There 
is  often  vomiting,  sometimes  diarrhoea.  The  pulse  is  increased  in 
frequency  out  of  proportion  to  the  gravity  of  the  case ;  it  may  be 
as  high  as  140  or  160  without  necessarily  indicating  danger.  The 
respirations  are  hurried,  and  there  is  often  a  distressing  cough,  with 
rales  and  rhonchi  in  the  chest.  The  urine  may  be  albuminous.  In 
a  small  proportion  of  cases  a  transient  rash,  consisting  of  minute 
rose  spots  smaller  than  those  of  typhoid  fever,  appears  over  the 
trunk  and  limbs. 

After  these  symptoms  have  continued  for  about  a  week  the 
attack  terminates  by  crisis,  the  temperature  suddenly  falling  to  a 
degree  or  two  below  normal.  The  onset  of  the  crisis  may  be 
ushered  in  by  profuse  sweating,  by  diarrhoea,  or  by  haemorrhage 
from  the  nose,  bowel,  or  uterus.  After  the  crisis  all  the  symptoms 
rapidly  subside,  and  the  patient  soon  feels  so  well  that  he  is  with 
ditificulty  convinced  that  the  disease  is  not  yet  over.  The  period 
of  intermission  continues  for  about  a  week  ;  then  the  relapse  sets 
in,  the  temperature  again  rises,  and  the  original  symptoms  recur. 
The  relapse  lasts  for  some  three  days,  and  ends,  like  the  original 
attack,  by  crisis.  In  the  majority  of  cases  the  disease  is  now  over, 
but  second,  and  even  third,  relapses,  with  inter\"ening  intermissions, 
have  been  known   10  occur.      In  rare  instances  there  is  no  relapse. 


RELAPSING   FEVER  141 

the  patient  recovering  after  the  subsidence  of  the  primary  f^.ver. 
Convalescence  is  always  slow  and  tedious. 

Such  is  the  usual  course  of  the  disease  ;  several  complications 
may,  however,  arise.  The  most  important  are :  collapse,  generally 
setting  in  about  the  crisis ;  severe  diarrhoea ;  purpura  with 
haemorrhages  into  the  skin  and  from  the  mucous  membranes; 
suppression  of  urine  ;  and  pneumonia.  Any  of  these  conditions 
may  prove  fatal.  The  pains  in  the  limbs  may  be  very  severe,  and 
may  continue  during  the  intermission  and  after  the  relapse. 
Bronchitis  is  sometimes  of  sufficient  severity  to  rank  as  a  com- 
plication. In  some  epidemics  ophthalmia  has  been  common  in  the 
early  days  of  convalescence ;  the  inflammation  starts  in  the  ciliary 
region,  and  ultimately  may  involve  all  the  structures  of  the  eye ; 
permanent  blindness  may  ensue,  but  fortunately  both  eyes  are 
seldom  affected.  Parotitis  was  frequently  observed  in  one  epidemic 
in  Russia.  Pregnant  women  almost  invariably  abort  when  attacked 
with  relapsing  fever. 

The  Spirillum  Obermeieri,  often  in  large  numbers,  is  present  in 
the  blood  during  the  febrile  stages.  During  the  intermission  it 
disappears  from  the  blood,  and  probably  collects  in  the  spleen. 

Pathology. — -The  spirilla  are  fine  corkscrew -shaped  bodies 
with  pointed  ends,  twice  to  five  times  as  long  as  the  diameter  of  a 
red  blood  corpuscle.  They  are  actively  motile,  and  retain  their 
motility  from  several  hours  up  to  as  long  as  fourteen  days  after 
removal  from  the  body,  according  to  the  temperature  at  which  they 
are  kept.  Attempts  to  cultivate  them  outside  the  body  have  hitherto 
failed  ;  so  that  we  still  lack  the  absolute  proof  that  they  are  the 
cause  of  the  disease,  although  there  can  be  but  little  doubt  that  this 
is  the  case.  The  disease  has  been  conveyed  both  to  the  human 
being  and  to  monkeys  by  the  injection  of  blood  containing  the 
spirilla.  In  monkeys  the  disappearance  of  the  spirilla  from  the 
blood  during  the  intermission  has  been  proved  to  be  due  to  their 
accumulation  in  the  cells  of  the  spleen.  We  know  nothing  definite 
about  the  mode  of  multiplication  of  the  spirilla  or  of  their  life 
history  outside  the  body.  From  analogy  with  the  malaria  parasite, 
it  is  probable  that  the  period  of  fever  corresponds  to  a  particular 
stage  in  the  development  of  the  spirilla,  and  that  other  stages  take 
place  during  the  intermission.  As  the  spirilla  are  not  found  in  the 
secretions  or  excretions,  it  is  difficult  to  explain  the  conveyance  of 
the  disease  from  patient  to  patient.  There  is,  however,  some 
experimental  evidence  of  conveyance  by  means  of  insects,  which 
would  be  quite  compatible  with  the  habits  of  the  patients  among 


142  Manual  of  medicine 

whom  the  disease  is  most  prevalent.     It  is  not  improbable  that  the 
organism  may  ultimately  be  found  to  belong  to  the  Protozoa. 

Diagnosis.  —  Relapsing  fever  may  be  mistaken  for  typhoid 
fever,  smallpox,  typhus,  influenza,  or  Weil's  disease.  The  onset  of 
typhoid  is  gradual,  while  that  of  smallpox,  typhus,  influenza,  and 
relapsing  fever  is  sudden.  Typhoid  fever  can  be  distinguished  by 
the  long  duration  of  the  pyrexia  ;  smallpox  and  typhus  by  the 
appearance  of  the  eruption  on  the  third  and  fifth  day  respectively ; 
infl-ienza  by  the  absence  of  enlargement  of  the  spleen  and  liver; 
and  Weil's  disease  by  the  absence  of  severe  nervous  symptoms.  In 
doubtful  cases  the  diagnosis  can  be  cleared  up  by  placing  a  drop 
of  the  blood  under  the  microscope  and  examining  for  motile 
spirilla.  If  the  blood  cannot  be  examined  fresh,  a  cover-glass 
preparation  should  ba  made  by  allowing  a  thin  film  of  blood  to  dry 
on  a  cover-glass.  The  film  is  fixed  by  passing  the  cover-glass 
rapidly  through  the  flame,  the  haemoglobin  is  extracted  with  i  per 
cent  solution  of  acetic  acid,  and  the  spirilla  stained  by  immersion 
for  a  few  minutes  in  one  of  the  aniline  dyes. 

Prognosis. — The  fatality  of  the  disease,  according  to  Murchison, 
is  4  per  cent.  Most  of  the  fatal  cases  occur  in  patients  over 
thirty;  in  patients  below  this  age  the  fatality  is  only  0.5  per  cent. 

Post-mortem  appearances. — The  spleen  is  large  and  soft, 
with  yellow  areas  the  size  of  a  horse-bean  scattered  throughout 
its  substance.  These  areas,  which  consist  of  necrosed  tissue,  con- 
tain a  large  number  of  spirilla.  Rupture  of  the  organ,  with  escape 
of  blood  into  the  peritoneal  cavity,  has  been  recorded.  The  liver 
is  enlarged ;  under  the  microscope  its  cells  show  cloudy  swelling, 
and  sometimes  a  small  celled  infiltration  around  the  portal  veins. 
The  kidneys  exhibit  cloudy  sweUing  of  the  epithelium,  coagulation 
casts  in  the  tubules,  and  perhaps  an  accumulation  of  small  cells 
in  the  interstitial  tissue.  Fatty  degeneration  occurs  in  the  muscle 
of  the  heart  and  in  the  voluntary  muscles. 

Treatment. — The  patient  should  be  isolated  and  kept  in  bed 
until  convalescence  is  well  established.  The  various  symptoms 
must  be  treated  as  they  arise ;  pyrexia  by  cold  sponging ;  suppres- 
sion of  urine  by  poultices  and  dry-cupping  to  the  loins ;  collapse 
by  stimulants ;  diarrhoea  by  opium  and  astringents ;  ophthalmia  by 
ths  instillation  of  atropine  and  by  the  application  of  leeches  to  the 
temples.  Murchison  recommended  the  routine  administration  of 
such  drugs  as  acetate  of  potash  and  digitalis,  with  the  object  of 
preventing  suppression  of  urine. 

J.  W.  Washbourn. 


YELLOW  FEVER  143 


YELLOW   FEVER 


A  miasmatic  contagious  disease,  caused  by  specific  microbic 
infection  and  characterised  by  an  acute  febrile  paroxysm,  followed 
by  pathognomonic  symptoms  indicative  of  toxaemic  jaundice,  with 
renal,  gastro-intestinal  and  hsemorrhagic  complications.  It  occurs 
in  endemic  form  in  some  areas,  elsewhere  in  epidemics. 

Geographical  distribution. — Its  endemic  areas  are  a  few  sea- 
coast  towns  in  the  West  Indies,  jNIexico,  Brazil,  and  Gulf  of  Guinea, 
notably  Vera  Cruz,  Havana,  Santiago  de  Cuba,  San  Domingo,  and 
Rio  de  Janeiro.  Epidemic  outbreaks  are  of  frequent  occurrence 
in  populous  centres  in  communication  with  these  cities,  but  rarely 
extend  far  inland,  or  to  high  altitudes,  or  where  the  temperature  is 
below  75°  F.  and  the  humidity  low.  Outbreaks  do  occur,  however, 
at  high  altitudes  and  in  temperate  zones.  Arid  and  sparsely 
populated  districts  do  not  suffer.  Asiatic  and  other  Eastern 
countries  are,  as  yet,  exempt,  but,  given  the  necessary  conditions, 
any  populous  centre  may  become  attacked  and  form  a  fresh  endemic 
area.  Thus  Rio  de  Janeiro,  which  was  first  attacked  in  1849,  has 
never  since  been  free. 

The  American  Atlantic  littoral  between  35°  S.  and  45°  N. 
latitude,  and  Sierra  Leone,  Senegal  and  Gambia  in  Africa,  have  ex- 
perienced frequent  outbreaks.  South-western  Europe  suffered  severely 
at  the  end  of  the  eighteenth  and  beginning  of  the  nineteenth  century, 
Gibraltar  losing  nearly  6000  persons,  or  more  than  one-third  of  its 
total  population,  during  an  epidemic  in  1804.  Another  severe 
epidemic  occurred  there  in  1828,  and  minor  outbreaks  in  1813  and 
1 8 14.  Since  1828  European  outbreaks  have  been  unfrequent, 
and,  wath  the  exception  of  an  epidemic  in  Lisbon  in  1856-57, 
insignificant.  They  occurred  at  Brest,  1856;  St.  Nazaire,  1861; 
Swansea,  1865;  and  Madrid,  1878.  The  Swansea  outbreak  caused 
fifteen  deaths,  all  of  persons  in  direct  or  indirect  communication 
with  an  infected  vessel  from  Cuba ;  in  the  Madrid  outbreak  thirty- 
five  died,  all  in  a  locality  where  soldiers,  recently  returned  from 
Cuba,  lived. 

Seasonal  prevalence. — In  endemic  areas  north  of  the 
equator  seasonal  activity  commences  in  June,  is  at  its  height  in 
July,  and  continues  with  little  diminution  till  December.  The 
disease  is  less  active  from  January  to  May.     In  Rio  these  conditions 


144  MANUAL  OF  MEDICINE 

are  reversed.  In  epidemic  zones,  outbreaks  usually  last  three 
months,  and  are  generally  confined  to  periods  of  tropical  heat,  but 
their  duration  varies  and  is  influenced  by  other  than  seasonal 
factors. 

Influence  of  race,  age,  and  sex. — No  individual  of  any  race 
can  claim  immunity  except  by  previous  attack.  Negroes,  Moors, 
Arabs,  Chinamen,  have  all  suffered  on  first  coming  into  endemic  or 
epidemic  areas.  Negroes  are  apparently  immune  in  the  endemic 
zone  or  where  epidemics  are  frequent,  but  this  is  attributed  to 
attacks  in  childhood,  probably  unrecognised.  On  the  other  hand, 
susceptibility  to  and  severity  of  attack  are  much  greater  in  white 
than  in  coloured  races,  and  in  northern  than  in  southern  Europeans. 
New  arrivals  in  endemic  areas  are  specially  susceptible,  but 
susceptibility  is  not  necessarily  lessened  by  prolonged  residence. 

Age  and  sex  influence  severity,  but  not  susceptibility,  children 
suffering  mildly,  and  females  less  severely  than  males. 

Bacteriology. — In  1897  Sanarelli  obtained  pure  cultures  of  a 
specific  bacillus,  bacillus  icferoides,  in  the  capillaries  of  the  liver  and 
kidneys,  never  in  the  digestive  tract,  of  persons  dying  in  the 
earlier  stages  of  yellow  fever.  In  later  stages  he  found  the  body 
invaded  with  intestinal  and  putrefactive  microbes  and  the  bacillus 
icteroides  incapable  of  detection.  Outside  the  body,  the  growth  of 
this  bacillus  is  specially  active  in  the  presence  of  moulds,  of  which 
it  appears  to  be  a  saprophyte,  and  it  presents  diagnostic  growths  on 
culture  media.  Sterile  cultures  injected  into  men  and  animals  had 
steatogenous,  emetic  and  hsematolytic  effects,  resembling  attacks  of 
yellow  fever.  The  conditions  favourable  for  conservation  of  the 
bacillus  are  humidity,  warmth,  darkness,  and  want  of  air.  It  lives 
long  in  sea-water,  resists  drying,  but  is  rapidly  killed  by  solar  rays. 
Others  have  described  specific  microbes,  but  their  conclusions  have 
been  rejected.  Sternberg  failed,  after  careful  investigation,  to 
detect  a  specific  microbe,  but  notices  the  invasion  of  the  body  by 
intestinal  bacilli.  The  features  of  Sanarelli's  bacillus  explain,  to 
some  extent,  the  fact  that  infection  is  specially  liable  to  persist  in 
old  wooden  hulks  and  in  dirty,  dark,  ill-ventilated  ships  and  dwell- 
ings of  tropical  sea-coast  towns.  Insanitary  surroundings  are 
necessary  for  the  propagation  of  the  disease.  Clean,  well-paved, 
well-drained  cities  suffer  slightly ;  those  with  reverse  conditions 
severely.  Moist  soil,  polluted  with  faecal  matter,  forms  the  best 
nidus,  and  a  system  of  cess-pits  in  the  endemic  zone  favours 
endemicit}'.  The  mode  of  entrance  of  infective  material  into  the 
body  is  uncertain.      Evidence  of  infection  by  the  digestive  tract  is 


YELLOW  FEVER  145 

hegative.  Air  convection  and  inoculation  by  stinging  or  biting 
insects  are  probable.  Bedding,  clothing  and  discharges  from 
patients,  ship's  cargoes,  etc.,  are  regarded  as  the  media  of  convey- 
ing, and  polluted  soil  as  the  medium  of  propagating  the  disease,  the 
requirements  for  the  development  of  an  epidemic  being:  (i)  the 
introduction  of  infective  material  by  sick  persons,  fomites,  ships, 
etc.  ;  (2)  favourable  conditions,  such  as  polluted  soil,  warmth,  and 
moisture ;  and  (3)  a  community  of  susceptible  persons.  It  is  not 
directly  infectious  from  person  to  person,  and  one  attack  usually 
confers  immunity. 

The  minimum  incubation  period  is  one  day,  the  maximum 
five.  Usually  it  is  two  to  four  days.  An  apparent  ten  days' 
period  has  been  noted,  but  records  of  longer  periods  are  involved 
in  fallacies. 

Clinical  history  and  symptoms. — There  may  be  malaise 
before  onset,  but  the  attack  is  usually  ushered  in  by  sudden  rigor 
with  rapid  rise  of  temperature  to  103°  or  104°  R,  and  of  pulse  to, 
no  or  120,  and  by  severe  orbital  and  lumbar  pain.  This  febrile 
paroxysm  lasts  two  to  five  days,  during  which  the  temperature 
shows  no  marked  rise  or  fall,  but  the  pulse-rate  steadily  declines. 
The  skin  is  usually  dry,  and  there  are  anorexia,  thirst,  and  restless- 
ness.  The  patient  feels  and  looks  very  ill.  The  face  is  turgid  and 
the  eyes  characteristically  suffused.  There  is  much  epigastric 
tenderness  with  vomiting,  at  first  of  the  contents  of  the  stomach, 
but,  later,  of  bile,  gastric  secretions,  and  mucus.  On  the  third  or 
fourth  day,  seldom  later,  rapid  defervescence  sets  in,  the  pains  dis- 
appear, the  body  becomes  cool  and  moist,  the  pulse  slows  to  40  or 
even  less,  and  a  stage  of  calm,  with  a  sense  of  comfort  and  well- 
being,  ensues.  This  is  deceptive  both  to  patient  and  physician, 
and  requires  careful  management.  In  a  few  hours  pathognomonic 
symptoms  develop,  more  or  less  rapidly,  according  to  the  severity 
or  otherwise  of  the  attack.  Yellowness  of  the  conjunctivae, 
gradually  extending  to  face  and  body,  diminished  secretion  of 
urine,  albuminuria,  and  an  abnormally  soft,  slow  pulse  are  in- 
variably noticed  early,  along  with  discomfort  in  the  epigastric 
region.  In  mild  cases  no  further  symptoms  may  develop,  and  on 
the  fifth  or  sixth  day  they  disappear  and  the  patient  rapidly 
convalesces.  In  severer  cases  the  icterus  deepens  and  extends 
rapidly,  the  urine  becomes  scanty,  loaded  with  albumen  and  casts, 
or  totally  suppressed,  and  active  delirium,  convulsions,  and  coma 
may  ensue,  although  in  other  cases  the  mind  may  remain  clear 
throughout.  Lumbar  pains  return,  abdominal  discomfort  increases, 
VOL.  I  h 


146  MANUAL  OF   MEDICINE 

vomiting  becomes  more  frequent,  at  first  of  blood-stained  or  "  coffee- 
ground  "  matter,  but  eventually  quantities  of  altered  blood, 
constituting  "black  vomit,"  may  be  ejected,  and  diarrhoea  with 
tarry  stools  may  set  in.  The  temperature  rises  or  the  body  may 
remain  cold  and  clammy.  Blood  oozes  from  the  lips  and  nostrils, 
and  occasionally  from  other  mucous  orifices.  Sordes  accumulate, 
the  pulse  becomes  feeble  and  slower,  and  a  "  typhoid  state,"  with 
peculiar  cadaverous  odour,  ensues.  Should  recovery  take  place, 
the  symptoms  gradually  disappear  about  the  tenth  day,  but  con- 
valescence may  be  complicated  by  boils,  abscesses,  parotitis  and 
hepatitis.  In  fatal  cases  death  is  most  frequent  on  the  fifth  or 
sixth  day  from  anuria  and  coma,  or  from  haemorrhage  and 
exhaustion,  but  it  may  occur  early  during  the  febrile  paroxysm  and 
before  pathognomonic  symptoms  are  prominent.  It  rarely  occurs 
after  the  tenth  day.  Recurrence  of  the  febrile  paroxysm  in  the 
stage  of  calm,  or  of  the  more  severe  symptoms  during  convalescence 
from  acts  of  indiscretion  is  not  uncommon,  especially  in  mild  cases, 
and  such  relapses  are  very  fatal. 

Diagnosis. — -The  febrile  paroxysm  resembles  the  onset  of  small- 
pox, dengue,  or  an  attack  of  malarial  fever.  During  an  epidemic  of 
yellow  fever  the  appearance  of  the  face,  the  suffused  eyes,  epigastric 
tenderness  and  severe  lumbar  pain  should  be  sufficient  for  early 
diagnosis,  and  absence  of  eruption  or  splenic  enlargement  and  tender- 
ness should  positively  exclude  eruptive  or  malarial  fevers.  The 
steady  decline  of  pulse -rate  from  the  first  day,  irrespective  of  a 
stationary  or  rising  temperature,  the  appearance  of  albuminuria 
and  icterus  on  the  second  or  third  day,  are  positive  signs  of  yellow 
fever.  Later,  anuria,  epigastric  discomfort  and  black  vomit,  tarry 
stools  and  soft  slow  pulse  form  a  group  of  symptoms  which  are  un- 
known in  other  diseases,  and  should  render  the  diagnosis  complete, 
although  in  mild  cases  many  of  these  symptoms  are  absent,  and, 
even  in  fatal  cases,  not  necessarily  present.  Quinine  checks 
malarial  but  not  yellow  fever,  and,  although  its  use  in  diagnosis 
is  historical,  it  is  deceptive,  on  account  of  the  defervescence  that 
takes  place  naturally  about  the  third  day  in  the  latter  disease. 
Serum  diagnosis  may  prove  valuable,  recent  experiments  showing 
that  the  serum  of  yellow  fever  patients  causes  agglutination  in 
cultures  of  the  bacillus  ideroides. 

Prognosis, — An  initial  temperature  of  io6°,  or  even  of  io8"  F., 
has  been  noted  occasionally,  and  is  always  fatal ;  and  the  rule  is 
that  the  lower  the  initial  temperature  the  milder  will  the  case  be. 
In  favourable  cases  the  urine  is  scantiest  on  the  third   day,  and 


YELLOW  FEVER  147 

then  gradually  increases;  in  unfavourable  cases  the  reverse  occurs, 
and,  if  anuria  sets  in,  death  almost  invariably  ensues.  Delirium 
and  coma,  and,  to  a  somewhat  less  extent,  black-  vomit  are  also 
usually  fatal  symptoms.  The  influence  of  race,  age  and  sex,  and 
also  of  relapses,  has  already  been  indicated.  A  previous  history  of 
alcoholism  is  specially  unfavourable,  as  is  also  a  high  degree  of 
albuminuria.  An  average  case  mortality  is  30  per  cent,  but  the 
ratio  varies  widely  in  different  epidemics. 

Pathological  anatomy. — The  body  is  stained  yellow,  blood 
trickles  from  and  is  caked  about  the  mucous  orifices,  and  there  is 
early  discoloration  from  purpuric  spots  or  hypostatic  congestion. 
The  yellov^  staining  is  due  to  altered  blood  pigment  and,  unless 
associated  with  biliary  jrundice,  is  mottled  rather  than  uniform, 
and  is  specially  marked  on  dependent  parts  and  where  there  has 
been  pressure.  Immediately  after  death  a  high  temperature  of 
ioS°  to  110°  may  be  noticed.  Cadaveric  rigidity  sets  in  early, 
blood  coagulability  is  diminished,  and  urine  found  in  the  bladder 
is  loaded  with  albumen.  The  liver,  except  in  the  earlier  stages, 
when  it  is  engorged  with  blood,  has  a  characteristic  dry  yellow  or 
yellowish-brown  wash-leather  appearance,  due  to  fatty  degeneration 
of  its  cells,  but  is  seldom  contracted  unless  there  is  concurrent 
cirrhosis  from  alcoholism.  The  stomach  is  generally  full  of  dis- 
integrated blood  and  its  mucous  membrane  congested  and  ecchy- 
mosed.  The  condition  of  the  small  intestine  is  similar,  but  the 
large  intestine  frequently  presents  no  abnormality.  In  the  kidneys 
hypersemia  in  the  early  stages  and,  later,  haemorrhages  beneath  the 
capsule  and  in  the  cortical  substance  are  noted,  and  the  tubules 
present,  microscopically,  the  appearances  of  acute  desquamative 
nephritis,  with  fatty  degeneration  of  their  epithelium.  The  serous 
cavities  usually  contain  some  yellow-stained  fluid  and  the  other 
organs  hsemorrhagic  infarctions  or  ecchymoses.  No  changes  have 
been  noticed  in  the  spleen. 

Treatment. — No  drug  cure  is  known,  and  active  medication 
must  be  avoided.  The  treatment  should  be  on  general  principles 
and  symptomatic.  Sternberg  recommends  that  three  tablespoonfuls 
of  a  mixture  containing  150  grains  of  soda  bicarbonate,  and  ^ 
grain  mercuric  chloride  in  a  quart  of  water  should  be  given  every 
hour  ice-cold,  to  lessen  gastric  irritability  and  acidity.  The  bowels 
should  be  unloaded  at  the  onse"  by  castor  oil,  though  some  prefer 
calomel.  Subsequently  enemata  only  should  be  used.  During  the 
febrile  paroxysm  simple  diaphoretics  and  sponging  are  best ;  but 
lowering  the  vital  powers  by  cold  sponging  at  the  time  of  defer- 


148  MANUAL  OF  MEDICINE 

vescence  must  be  guarded  against,  and,  for  the  same  reason,  it  is 
best  to  avoid  cold  baths  at  any  period.  Hot  applications  to  the 
loins  should  be -applied  early.  Cold-water  enemata  and  dry  cup- 
ping are  also  useful  in  relieving  renal  congestion.  When  scantiness 
or  suppression  of  urine  is  feared,  pilocarpin  hydrochlorate,  |^  to  ^^ 
grain,  may  be  injected  hypodermically.  After  defervescence, 
diffusible  stimulants,  especially  champagne,  are  usually  required, 
but  some  prefer  digitalis  and  strychnine,  administered  hypodermic- 
ally.  Good  nursing  and  careful  dieting  are  of  paramount  import- 
ance. Absolute  rest  in  bed,  very  little  food  by  the  stomach,  and 
that  only  in  fluid  form,  given  cold,  and  in  small  quantities,  are 
essential,  especially  in  the  stage  of  calm.  Nutrient  enemata  should 
then  be  employed  and  gastric  discomfort  relieved  by  sinapisms. 
Opium  must  be  avoided.     Return  to  solid  food  must  be  very  gradual. 

Recently  serum  therapy  has  been  employed  by  Sanarelli  with 
some  success,  both  as  curative  and  prophylactic.  The  serum 
is  obtained  from  horses  or  oxen  prepared  during  a  long  period  by 
inoculations  of  bacillus  icteroides  cultures.  It  is  supposed  to  be 
bactericidal  in  action,  but  not  a  true  antitoxin,  and  it  is  con- 
sequently most  successful  in  the  early  stages,  and  when  injected 
into  veins.  It  is  useless  when  anuria  is  present,  but,  in  Sanarelli's 
experience,  always  prevented  h^emorrhagic  symptoms.  As  a 
prophylactic  it  had  successful  results  when  inoculated  into  persons 
living  in  infected  areas  during  an  epidemic. 

Other  preventive  treatment  consists  in  attention  to  general 
cleanliness,  exposing  dark  corners  to  light  and  air,  abatement  of 
overcrowding  and  removal  of  causes  of  soil  pollution.  Ship  epidemics 
may  be  stopped  by  sailing  to  cold  latitudes ;  troop  epidemics  by 
moving  from  the  infected  locality.  Disinfection  of  infected 
clothing,  bedding  and  discharges,  as  well  as  of  habitations,  should 
be  scrupulously  and  S5fstematically  carried  out.  ^Vhere  cremation 
is  not  adopted,  it  is  essential  to  fill  the  coffins  and  graves  of  those 
who  have  died  with  strong  disinfectants,  such  as  chloride  of  lime. 
Isolation  of  patients  is  practised  as  a  matter  of  routine.  In  the  war 
between  America  and  Spain  in  1898  the  rule  was  to  keep  prisoners 
from  infected  localities  isolated  under  observation  for  seven  days,  to 
disinfect  all  their  clothing  and  belongings,  and  to  burn  the  surface 
of  polluted  soil 

W.  G.  Macpherson. 


WEIL'S  DISEASE  149 


WEIL'S  DISEASE 

In  1886  Weil  {Deut.  Archiv  filr  kiln.  Med.  xxxix.)  described 
four  cases  of  an  acute  febrile  disease  associated  with  jaundice, 
nephritis,  and  enlargement  of  the  spleen.  A  number  of  cases  with 
similar  clinical  symptoms  have  since  been  recorded,  especially  in 
Germany,  and  the  name  Weil's  disease  has  been  attached  to  the 
malady.  It  appears  to  be  a  definite  specific  disease,  and  it  is  prob- 
able that  it  was  previously  described  under  various  designations. 

Clinical  characters. — The  onset  of  the  illness  is  generally 
quite  sudden,  the  patient  being  seized  with  headache,  pains  in  the 
calves,  vomiting  and  diarrhcea,  faintness,  or  rigors.  The  tempera- 
ture quickly  rises  to  between  102""  F.  and  104°  F.,  and  continues 
high  throughout  the  attack,  which  is  accompanied  with  the  usual 
symptoms  of  pyrexia — thirst,  loss  of  appetite,  rapid  pulse,  furred 
tongue,  etc. 

In  addition  there  are  certain  symptoms  special  to  the  disease. 
Gastro-intestinal  disturbances  are  sometimes  prominent  features,  the 
patient  suffering  from  frequent  vomiting  and  profuse  diarrhoea. 
Acute  nephritis  is  an  early  and  fairly  constant  symptom  ;  its  presence 
is  indicated  by  the  appearance  of  albumen,  casts,  and  sometimes 
blood  in  the  urine.  The  splee7i  is  frequently  enlarged,  and  hsemor- 
rhages  may  appear  in  the  skin  and  subcutaneous  tissue.  The 
nervous  system  is  often  profoundly  affected,  as  shown  by  headache, 
restlessness,  and  delirium.  Jmmdice  is  of  constant  occurrence ;  it 
comes  on  about  the  fourth  or  fifth  day  of  the  attack  ;  bile  pigment 
and  occasionally  crystals  of  tyrosin  appear  in  the  urine ;  and  the 
stools  are  sometimes  devoid  of  colour.  The  liver  may  become 
enlarged  and  tender. 

After  the  symptoms  have  lasted  about  ten  days  they  usually 
subside,  the  temperature  gradually  falls,  and  the  jaundice  and 
nephritis  clear  up.  Convalescence  is  always  slow,  and  it  is  some 
time  before  the  patient  has  recovered  his  usual  health.  Relapses 
are  by  no  means  uncommon  during  convalescence ;  about  a  week 
after  the  temperature  has  become  normal,  it  rises  again  to  102°  F. 
or  104°  F.,  and  there  may  be  a  return  of  the  jaundice  and  nephritis. 

The  attack  does  not  always  end  in  recovery ;  Jaeger  records 
three  deaths  out  of  nineteen  cases. 

Post-mortem   appearances, — The    tissues    arc    bile-stained. 


ISO  MANUAL  OF  MEDICINE 

and  haemorrhages  may  be  found  in  the  subcutaneous  and  sub- 
pjritoneal  tissue,  and  the  endocardium.  The  s;jleen  is  either  en- 
larged or  normal  in  size.  The  mucous  membrane  of  the  stomach 
and  intestines  may  be  reddened  and  swollen,  an  infiltration  of 
small  round  cells  being  found  on  microscopical  examination.  The 
principal  changes  are  found  in  the  liver  and  kidneys.  The  former 
,does  not  show  much  alteration  to  the  naked  eye,  except  perhaps 
that  it  is  a  little  enlarged ;  but  microscopically  profound  changes 
are  to  be  observed.  The  liver  cells  have  undergone  fatty  degenera- 
tion, and  areas  are  found  scattered  throughout  the  organ  in  which 
the  structure  of  the  lobules  is  lost  and  the  cells  are  broken  down 
into  a  granular  or  fatty  detritus.  Areas  of  small  round-celled  in- 
filtration are  also  found.  The  kidneys  are  swollen  and  sometimes 
streaked  with  haemorrhages ;  cloudy  swelling  and  fatty  changes  are 
found  in  the  cells,  and  a  small  round-celled  infiltration  is  present 
between  the  tubules. 

Pathology. — -From  this  short  description  it  will  be  seen  that 
the  disease  resembles  a  septicaemia  in  which  the  effect  of  the  virus 
especially  falls  upon  the  liver  and  kidney ;  the  jaundice  is  due  to 
the  degeneration  of  the  liver  cells,  and  the  nephritis  is  set  up  by  the 
injury  to  the  cells  of  the  kidney.  This  view  is  further  supported 
by  the  researches  of  Jaeger,  who  found  a  bacillus  belonging  to  the 
Proteus  group  in  the  spleen,  liver,  and  kidneys  of  two  fatal  cases, 
and  in  the  urine  of  several  cases  during  life.  This  group  of  bacilli 
contains  several  species.  Some  are  well  known  as  the  cause  of 
putrefaction  in  animal  and  vegetable  matter ;  while  one  member — 
the  Proteus  hominis  capsulatus — is  the  cause  of  an  acute  septicaemia 
occurring  among  rag-sorters  in  Italy,  the  virus  being  probably  in- 
haled with  the  dust  from  the  rags.  There  is  thus  good  reason  to 
believe  that  the  protcus  obtained  by  Jaeger  (Zeitschrift  filr  IIygie?ie, 
Bd.  xii.  1892)  is  the  cause  of  Weil's  disease,  and  the  frequent 
occurrence  of  gastro-intestinal  disturbances  points  to  the  mode  of 
infection  being  through  the  alimentary  tract.  The  disease  occurs 
most  frequently  between  June  and  September,  when  putrefactive 
changes  are  at  their  height ;  one  of  Jaeger's  patients  attributed  his 
attack  to  eating  a  bad  sausage,  several  to  bathing  in  foul  w^ater ; 
and  it  is  significant  that  many  of  the  sufferers  from  this  disease 
have  been  engaged  in  work  at  slaughter-houses  and  sewers.  Jaeger 
mentioned  an  epidemic  among  fowls  due  to  a  bacillus  similar  to 
the  one  he  found  in  the  human  cases,  and  he  believed  that  the 
water  in  which  his  patients  had  bathed  was  contaminated  with  the 
excreta  of  infected  fowls, 


WEIL'S  DISEASE  151 

Weil's  disease  bears  a  close  resemblance  to  acute  yellow  atrophy 
in  clinical  symptoms  and  in  the  changes  found  in  the  liver.  In 
both  diseases  a  poison  causes  degeneration  of  the  liver-cells  ;  in 
Weil's  disease  the  poison  appears  to  be  the  proteus  bacillus ;  while 
in  acute  yellow  atrophy  the  nature  of  the  poison  is  unknown. 

Diagnosis. — Clinically  Weil's  disease  has  to  be  distinguished 
from  yellow  fever,  acute  yellow  atrophy,  phosphorus  poisoning,  and 
relapsing  fever.  The  first  named  malady,  which  closely  resembles 
Weil's  disease  in  the  acuteness  of  onset,  with  rigors,  pyrexia,  and 
other  febrile  symptoms  and  subsequent  development  of  jaundice,  is 
to  be  recognised  by  a  history  of  contagion,  no  enlargement  of  the 
spleen,  and  later  by  the  occurrence  of  black  vomit.  A  fall  in  the 
pulse-rate  after  the  first  day,  notwithstanding  a  continued  high 
temperature,  has  also  been  said  to  be  characteristic  of  yellow  fever. 
In  acute  yellow  atrophy  jaundice  occurs  for  several  days  before 
severe  constitutional  disturbances  arise,  while  in  Weil's  disease 
pyrexia  and  severe  constitutional  disturbances  occur  before  the 
jaundice  sets  in.  The  same  remark  applies  to  phosphorus  poison- 
ing, and  in  this  disease  the  history  or  the  presence  of  phosphorus 
in  the  vomit  will  remove  all  doubt.  Relapsing  fever,  especially 
that  form  which  is  described  as  "bilious  typhoid,"  is  very  similar 
to  Weil's  disease,  and  the  occurrence  of  a  relapse  in  the  latter 
renders  the  resemblance  more  striking.  The  presence  of  the 
characteristic  spirilla  in  the  blood  in  relapsing  fever  is  the  most 
certain  means  of  distinction.  Various  forms  of  febrile  jaundice 
may  also  be  mistaken  for  Weil's  disease. 

The  treatment  of  Weil's  disease  should  be  based  on  general 
principles ;  perhaps  intestinal  antiseptics,  such  as  salol,  are  of 
benefit. 

J.  W.  Washbourn. 


152  MANUAL  OF  MEDICINE 


ANTHRAX 

Syn.  Malignant  Pustule,  Woolsorters'  Disease,  Splenic 
Fever,  Charbon 

Accounts  of  anthrax  exist  from  the  earliest  time,  and  there  have 
been  innumerable  epidemics,  destroying  large  numbers  of  herbivora, 
both  domestic  and  wild,  and  occasionally  infecting  men.  Sheep, 
horses,  and  oxen  are  especially  liable  to  this  disease,  whilst  carnivor- 
ous animals  are  but  slightly  susceptible.  In  cattle,  the  disease  may, 
according  to  Bollinger,  take  three  forms — (i)  Respiratory.  In  this, 
the  animal  may  become  unconscious,  and  convulsed  with  rapid 
breathing,  and  die  within  a  few  hours.  (2)  An  intestinal  form,  in 
which  blood  passes  with  the  fjeces ;  there  is  marked  pyrexia,  and 
sometimes  convulsive  movements.  (3)  Brawny  inflammatory  swell- 
ings appear  on  the  neck  and  body,  which  are  very  apt  to  slough. 

The  spleen,  in  all  these  forms,  is  greatly  enlarged  and  softened, 
hence  the  name  "  splenic  fever,"  which,  however,  is  less  suitable  for 
the  disease  as  it  appears  in  man,  owing  to  the  usual  absence  of  any 
characteristic  changes  in  the  appearance  of  that  organ.  It  is  a 
specific  infective  disease,  which  is  most  frequently  conveyed  to  men 
by  handling  or  coming  in  contact  with  the  hides,  hair,  or  carcases 
of  infected  animals.  It  is  due  to  the  introduction  of  the  bacillus 
anthracis,  which  multiplies  rapidly  at  the  seat  of  inoculation,  and 
only  after  an  interval  of  some  days  is  distributed  throughout  the 
circulation.  The  rapid  growth  of  the  bacilli  in  the  capillaries  sets 
up  numerous  haemorrhages ;  the  bacilli  may  be  excreted  by  the 
fceces,  the  bile,  and  the  urine. 

Bacteriology. — The  bacilli  are  elongated  cells  5  to  20  /*  in 
length,  and  rather  less  than  1.5  /x  broad,  straight  or  slightly  concave, 
and  immobile  (Plate  11. ).  They  multiply  rapidly  between  the 
temperatures  of  30°  C.  and  40°  C,  in  a  neutral  or  alkaline  medium, 
and  are  Eerobic.  When  abundantly  supplied  with  oxygen,  they 
form  elongated  threads  and  spore  readily ;  but  in  the  living  body, 
owing  to  the  insufficiency  of  oxygen,  they  develop  but  short  rods, 
and  no  spores.  The  latter  are  singularly  resistant  to  heat,  and 
retain  their  vitality  in  the  soil  for  long  periods.  When  cultivated 
on  -gelatine,  they  liquefy  the  medium  from  above  downwards,  and 
their  appearance  in  stab  culture  is  characteristic, 


ANTHRAX  153 

Anthrax  is  met  with  in  men  as  a  Malignant  Pustule  or 
cutaneous  infection  ;  it  occurs  in  those  who  handle  hides  and  hair, 
less  often  in  knackers  or  butchers  who  deal  with  carcases,  and  but 
seldom  in  farm  labourers  or  shepherds  who  are  in  contact  with  the 
living  animals,  and  is  still  more  rarely  communicated  directly  from 
one  person  to  another.  The  disease  is  not  common  in  England, 
and  in  London  most  of  the  cases  occur  in  the  tanyards,  which  are 
aggregated  in  the  district  of  Bermondsey,  and  hence  the  great 
majority  of  those  affected  are  admitted  to  Guy's  Hospital,  where 
eighty-three  cases  have  been  treated  during  the  past  twelve  years, 
of  which  thirteen  proved  fatal,  while  only  twenty  were  observed 
between  187  3-1 883. 

Symptoms. —  In  almost  every  case  the  initial  lesion  is  on  an 
exposed  part,  such  as  the  face,  neck,  or  occasionally  the  hands,  due 
to  the  inoculation  of  some  scratch,  pimple,  or  abrasion,  which  is  very 
often  produced  when  carrying  a  bale  of  hides.  A  slight  amount  of 
itching  is  noticed  at  first ;  a  papule  forms,  this  soon  passes  on  to  a 
vesicle,  which  is  readily  ruptured  and  soon  dries  up,  the  spot  being 
irritable  and  rather  painful.  About  the  third  day  there  is  an  inflam- 
matory swelling,  and  soon  the  characteristic  appearances  begin  to 
develop.  They  consist  of  a  depressed  black  scar,  surrounded  by  a 
raised  ring  of  small  vesicles,  while  for  some  distance  around  there 
is  a  firm  oedema,  which  gradually  becomes  brawny,  and  spreads  ex- 
tensively in  all  directions.  The  adjacent  lymphatic  glands  become 
enlarged  and  tender.  If  the  spot  be  on  the  face,  it  will  quickly 
lead  to  extensive  oedema,  sufficient  to  close  the  eyelids.  The 
nodule  does  not  suppurate,  hence  the  unfitness  of  the  name 
"  pustule,"  but  discharges  only  serous  fluid,  in  which  anthrax  bacilli 
may  generally  be  found.  The  pain  is  chiefly  due  to  the  tension, 
and  is  not  severe.  The  temperature  is  raised.  There  are  often 
symptoms  of  great  depression  with  rigors,  followed  by  vomiting, 
and  not  unfrequently  delirium.  Unless  active  local  measures  are 
adopted,  the  toxaemia  increases,  and  within  about  four  days  the 
bacilli  may  become  widely  distributed  through  the  system.  The 
disease  is  not  necessarily  fatal ;  death  may  occur  between  the  fifth 
and  eighth  days,  but  some  intercurrent  trouble,  such  as  oedema  of 
the  larynx,  which  is  not  uncommon  when  the  pustule  is  on  the 
neck,  may  cause  death  even  earlier. 

The  cutaneous  forms  of  the  disease  may  be  associated  with  one 
or  both  of  the  following  : — 

WooLSORTERs'  DISEASE. — This  is  the  respiratory  variety  of  the 
affection.       It    was   noticed   in   Bradford    fifty  years   ago,   after    the 


154  MANUAL  OF  MEDICINE 

introduction  of  alpaca  and  mohair,  that  there  were  occasionally 
deaths  with  pulmonary  symptoms  amongst  the  men  who  handled 
the  hair,  which  were  then  inexplicable ;  and  it  is  chiefly  in  this 
district  that  the  majority  of  the  cases  of  anthrax  infection  of  the 
lungs  have  been  noticed  in  this  country. 

If  the  fleeces  of  animals  which  have  had  anthrax  are  slightly 
damp,  or  if  they  are  greasy  owing  to  the  natural  fat  or  lanoline  in 
them,  there  is  but  little  dust,  and  but  little  risk  of  pulmonary  in- 
fection. The  infected  hair  of  the  camel,  vicuna,  llama,  alpaca  and 
horse,  which  have  no  grease,  are  therefore  the  most  dangerous. 

Symptoms. — These  are  very  obscure ;  the  patient  may  simply 
feel  chilly  and  ill,  complain  of  oppressed  breathing  and  be  dead 
within  a  few  hours.  In  the  less  acute  cases  the  patient  may  be 
very  ill,  but  there  are  generally  no  marked  physical  signs  of  disease 
in  the  lungs  beyond  rales  and  rhonchi,  and  sputum  which  is  blood- 
stained. The  temperature  is  raised  several  degrees,  but,  in  con- 
sequence of  the  collapse,  tends  to  drop  below  normal,  except  in  the 
rectum.  The  pulse  is  small,  rapid,  and  feeble.  The  prostration  is 
out  of  all  proportion  to  the  physical  signs.  Just  before  death 
bacilli  can  be  found  in  the  blood,  but  it  is  generally  impossible 
to  detect  them  at  an  early  stage  ;  the  sputum  would  probably  be 
found  to  contain  bacilli  much  earlier  in  the  disease.  Those  who 
survive  a  week  generally  recover. 

Intestinal  Anthrax.  —  Infection  has  been  stated  to  occur 
from  the  meat  or  milk  of  diseased  animals  ;  but  is  of  very  rare 
occurrence.  In  this  country  it  has  only  been  observed  associated 
with  the  cutaneous  or  pulmonary  varieties.  Besides  slight  pyrexia, 
prostration,  and  collapse,  there  will  be  vomiting,  purging,  and 
abdominal  pain,  and  the  dejecta  will  contain  blood. 

In  these  internal  forms  of  anthrax  there  may  be  delirium,  or 
convulsions  in  fatal  cases,  though  sometimes  the  mental  state  is 
unimpaired. 

Diagnosis. — The  absence  of  suppuration,  of  any  sloughing 
core  or  of  severe  pain,  together  with  the  presence  of  a  central 
eschar,  with  a  surrounding  ring  of  vesicles,  and  the  brawny  oedema 
of  the  adjacent  connective  tissue  are  characteristic,  and  distinguish 
anthrax  from  carbuncle.  The  lesion  is  a  single  one,  which  is  not 
the  case  in  glanders.  It  is  always  desirable  to  take  a  drop  of  the 
serum  from  a  vesicle,  or,  if  this  be  negative,  also  a  drop  from  the 
oedematous  tissue ;  stain  it  with  methylene  blue  and  examine  for 
the  bacilli,  which  will  generally  be  present ;  though  in  a  few  cases 
of  undoubted  malignant  pustule  they  could  not  be  found, 


ANTHRAX  155 

In  doubtful  cases,  especially  when  there  is  no  skin  lesion  and  a 
history  of  exposure  to  the  infection  is  uncertain,  a  mouse  should  be 
inoculated  with  a  drop  of  the  patient's  blood,  which,  if  the  disease 
be  anthrax,  will  prove  fatal  in  two  or  three  days,  and  the  blood  of 
the  animal  will  show  the  characteristic  baciUi. 

Prognosis. — The  mortality  of  cases  of  malignant  pustule  on 
the  head  or  neck  at  Guy's  Hospital  is  about  20  per  cent,  whereas 
when  the  pustule  is  on  the  hand,  not  more  than  one  in  ten  dies. 
The  onset  of  very  extensive  oedema  in  the  neck  adds  gravely  to  the 
risk ;  when  the  pustule  has  been  excised  the  oedema  often  subsides 
considerably.  Hurried  respiration  with  cough,  or  severe  diarrhoea 
and  vomiting  are  very  suggestive  of  general  infection.  A  very 
rapid,  feeble  pulse  is  of  evil  import.  At  first  the  bacilli  are  limited 
to  within  an  inch  or  two  of  the  seat  of  inoculation,  but  after  four 
days  they  tend  to  be  widely  distributed.  Towards  the  end,  in  fatal 
cases,  the  bacilli  can  be  found  in  the  urine,  and  not  unfrequently  in 
the  faeces  and  sputum,  yet  this  does  not  necessarily  indicate  a  fatal 
issue,  as  several  patients  who  passed  bacilli  in  their  urine  for  some 
days,  or  even  longer,  ultimately  recovered.  When  the  meninges  of 
the  brain  are  involved,  delirium  and  coma  with  convulsions  may 
develop.  The  mortality  of  cases  of  malignant  pustule  occurring  in 
South  America  and  in  Africa  is  infinitely  less  than  when  workmen 
in  London  are  infected.  It  is  difficult  to  explain  this,  except  by 
the  large  amount  of  meat  which  the  former  consume,  and  by  their 
physical  vigour  and  open-air  life.  The  degree  of  protection  con- 
ferred by  an  attack  appears  to  be  limited,  as  cases  have  been  met 
with  where  patients  have  had  more  than  one  attack  of  anthrax. 

Post-morteni  appearances. — Decomposition  is  rapid,  the 
skin  is  greatly  discoloured,  there  is  extensive  cedema  in  the  region 
of  the  pustule,  and  very  often  in  the  connective  tissue  of  the  anterior 
mediastinum.  Numerous  small  extravasations  of  blood  may  be 
seen  in  various  parts  of  the  body,  and  anthrax  bacilli  will  be  found 
in  such  places.  On  examining  small  and  inconspicuous  haemor- 
rhages on  the  mucous  membrane  of  the  alimentary  canal,  on  the 
meninges  of  the  brain,  and  also  on  the  pericardium,  I  seldom  failed 
to  find  bacilli.  Occasionally  extensive  extravasations  of  blood  may 
take  place,  into  or  on  the  surface  of  the  brain ;  or  into  the  intes- 
tines. The  serous  cavities  often  contain  fluid,  in  which  the  bacilli 
will  be  found. 

It  is  rare  to  find  evidence  of  pneumonia,  even  in  the  pulmonary 
cases,  but  microscopical  sections  will  show  extensive  haemorrhages, 
with  innurnerable  bacilli  blocking   up   the   capillaries.      Souietimes 


156  MANUAL  OF  MEDICINE 

portions  of  the  mucous  membrane  of  the  alimentary  canal  will  be 
raised  up  by  oedema,  so  as  to  form  distinct  swellings ;  in  places 
there  will  be  haemorrhages,  and  rarely  a  small  central  slough.  The 
condition  of  the  spleen  varies  ;  it  is  generally  soft ;  but  often  it  is 
not  enlarged.  The  abdominal  lymphatic  glands  are  frequently 
swollen. 

Treatment. — The  essential  treatment  for  a  pustule  is  to  remove 
it  entirely,  and,  where  indicated,  incise  the  brawny  tissue  freely.  The 
wound  is  then  generally  packed  with  iodoform,  and  some  surgeons 
inject  carbolic  acid  (5ss.  of  a  2  per  cent  solution  several  times 
daily)  into  the  adjacent  tissue.  A  number  of  cases  have  also  been 
treated  with  ipecacuanha  both  locally  and  internally  in  large  doses. 
Although  evidence  has  been  adduced  suggesting  that  this  drug 
might  be  of  value,  the  result  of  experience  at  Guy's  Hospital  has 
been  to  show  that  a  series  of  cases  so  treated  have  not  done  better 
than  those  where  it  had  not  been  employed.  Up  to  the  present 
time  no  efficient  treatment  by  an  antitoxin  has  been  available. 

Good  feeding,  of  which  meat  in  some  form  should  constitute  a 
considerable  proportion,  and  stimulants,  with  quinine,  are  essential ; 
many  of  even  the  most  unpromising  cases  ultimately  recover. 

G.  Newton  Pitt. 


TETANUS 


Tetanus  is  a  specific  infective  disease,  characterised  by  tonic 
spasms,  chiefly  affecting  the  muscles  of  the  face  and  trunk,  usually 
of  traumatic  origin,  tending,  with  a  somewhat  acute  course,  towards  a 
fatal  issue. 

Bacteriology. — The  disease  is  the  result  of  infection  by  an 
organism  which  was  tirst  obtained  in  pure  cultivation  in  1889.  The 
bacillus  is  extremely  slender,  with  rounded  ends,  and  varies  in  length 
from  4  IX  upwards.  The  threads,  except  when  very  short,  are  motile, 
but  after  growing  for  about  thirty  hours  at  a  temperature  of  37°  C. 
spores  begin  to  form,  the  threads  segment,  and  motility  ceases. 
The  spores  which  occur  at  the  end  of  the  segments  distend  them,  and 
hence  the  name  "  drum-stick  "  bacillus  ;  they  are  extremely  difficult 
to  destroy  (Plate  II.).  The  organism  is  an  obligate  anaerobe,  i.e.  it 
requires  an  atmosphere  free  from  oxygen  for  its  full  development, 


TETANUS  157 

otherwise  the  virulence  of  the  poison  produced  is  greatly  diminished. 
It  grows  freely  between  the  temperatures  of  14°  C.  and  42°  C, 
especially  in  a  medium  containing  2  per  cent  of  grape  sugar.  In  a 
stab  culture  it  liquefies  gelatine.  Owing  to  the  resistent  nature  of  the 
spores  a  pure  culture  may  be  obtained  by  raising  a  mixed  growth  to 
a  temperature  of  80°  C.  for  an  hour,  which  is  sufficient  to  destroy  the 
other  organisms. 

The  tetanus  bacillus  is  abundant  in  garden  earth,  in  dust,  and  in 
excrement,  especially  in  that  of  horses,  but,  fortunately,  its  virulence 
is  feeble  where  it  has  grown  in  the  presence  of  air. 

The  conditions  required  to  produce  tetanus  experimentally 
are  found  to  be  somewhat  complex.  If  an  animal  be  inocu- 
lated with  tetanus  bacilli,  there  is  no  local  suppuration,  and  unless 
the  growth  be  an  exceptionally  virulent  one,  no  further  symptoms 
may  result,  as  the  tissues  appear  to  be  capable  of  destroying  the 
organism.  To  produce  tetanus,  this  protective  mechanism  must  be 
hindered,  which  may  be  done  in  several  ways,  either  by  introducing 
at  the  same  time  some  tetanus  toxin  ;  by  traumatic  injury  to  the 
tissue  ;  or  by  a  mixed  infection  with  pyogenic  cocci,  which,  by 
absorbing  oxygen  from  the  tissues,  enhance  the  virulence  of  the 
poison  produced  by  the  tetanus  bacilli,  and  allow  them  to  develop 
more  freely  with  less  interference  from  the  living  tissues. 

The  bacilli  remain  localised  at  the  seat  of  inoculation,  and  are 
to  be  found  neither  in  the  blood  nor  in  the  other  tissues.  The 
poison  is  produced  very  slowly,  but  it  is  one  of  the  most  virulent 
which  is  known,  as  3-^  minim  of  a  filtered  alkaline  broth  culture 
of  the  microbes,  three  weeks  old,  is  sufficient  to  kill  a  rabbit. 

The  poison  can  be  obtained  from  the  blood,  spleen,  liver,  spinal 
cord,  urine,  etc.,  of  a  patient  with  tetanus,  by  precipitation  with 
alcohol.  The  introduction  of  the  toxin  without  any  bacilli  is  capable 
of  producing  all  the  symptoms  of  tetanus,  and  hence  the  removal  of 
the  seat  of  infection  so  as  to  stop  the  production  of  the  toxin  has 
been  regarded  as  an  important  part  of  the  treatment.  It  has  been 
shown  that  the  poison  has  a  definite  affinity  for  the  nerve  cells,  for 
if  a  suitable  portion  of  brain  or  spinal  cord  be  rubbed  up  into  an 
emulsion  with  an  otherwise  fatal  dose  of  tetanus  toxin  and  injected 
into  an  animal,  no  symptoms  of  tetanus  will  ensue,  as  the  poison 
appears  to  be  fixed  by  the  nerve  elements.  That  the  toxin  is  not 
heutrahsed  is  shown  by  the  fact  that  if  the  nerve  tissue  be  only  in- 
jected close  to  the  spot  where  the  poison  has  been  inserted,  it  does 
not  prevent  the  development  of  the  symptoms. 

When  an  animal  has  been  successfully  inoculated  with  tetanus, 


1S8  MANUAL  OF  MEDICINE 

there  is  a  short  incubatory  period,  after  which  tonic  spasms  develop 
in  the  muscles  near  the  seat  of  infection.  These  are  due  to  the 
action  of  the  poison,  which  appears  to  spread  up  to  the  spinal  cord 
by  the  nerves,  and,  acting  on  the  adjacent  cells  of  the  anterior 
horn,  increases  their  irritability.  Later  on,  the  poison  is  diffused 
through  the  body  by  means  of  the  blood  vessels,  so  that  all  the 
nerve  cells  become  subject  to  its  influence.  The  spasms  spread  to 
the  muscles  of  the  face,  neck,  and  trunk,  and  soon  become  almost 
universal. 

Etiology.  —  Generally  on  examination  a  local  injury  can  be 
found,  which  may  have  been  a  severe  one,  such  as  a  compound 
fracture,  or  an  operation  such  as  ovariotomy ;  but  in  many  cases 
there  has  been  only  some  slight  abrasion  or  a  punctured  wound, 
commonly  on  the  feet,  hands,  or  face,  particularly  in  persons  liable 
to  come  in  contact  with  soil  or  garden  mould.  In  some  no  definite 
injury  has  been  noticed ;  these  are  called  idiopathic,  and  have  been 
especially  observed  in  time  of  war,  where  men  have  been  exposed 
to  much  wet  and  cold.  Most  of  those  cases  which  have  been 
observed  after  parturition  have  been  reported  from  the  tropics. 
Some  were  premature  deliveries,  others  at  full  time,  but  in  several 
the  uterus  had  been  plugged  for  haemorrhage. 

Tetanus  neonahirum  occurs  in  new-born  children  in  whom  there 
has  been  infection  of  the  umbilical  cord,  and  is  very  prevalent  in 
some  islands,  often  as  an  epidemic. 

Men  are  much  more  frequently  affected  than  women  in  the 
proportion  of  about  six  to  one  ;  this  is  probably  due  to  their  in- 
creased exposure  to  injuries.  The  disease  may  occur  at  any  age, 
more  especially  in  the  young  and  active ;  but,  excluding  the  cases 
which  occur  within  the  week  after  birth,  it  is  rare  before  the  age  of 
five  years.  On  the  whole  the  disease  is  more  prevalent  in  hot 
climates. 

Incubation  period. — It  is  difficult  to  fix  this,  but  in  acute 
cases,  which  run  a  rapid  course,  the  symptoms  appear  within  four 
or  five  days  after  injury,  and  occasionally  sooner  ;  the  interval  is 
usually  under  two  weeks.  The  interval  varies  with  the  amount  of 
the  poison  introduced. 

Symptoms. — Tetanus  commonly  commences,  a  few  days  after 
an  injury,  with  symptoms  of  a  stiff  neck  or  of  a  sore  throat,  which  are 
at  first  considered  to  be  trivial,  or  the  patient  finds  that  there  is  a 
difficulty  in  opening  his  jaws  owing  to  a  tonic  spasm  of  the  mas- 
seters,  whence  the  name  of  lockjaw  or  "trismus."  In  other  cases 
the  first  indication  is  a  set  and  aged  expression,  due  to  the  contraction 


TETANUS  159 

of  the  facial  muscles,  so  that  there  is  a  fixed  smile  with  a  great 
increase  in  the  naso-labial  folds,  to  which  the  term  "  risus  sardonicus  " 
is  applied.  The  forehead  is  wrinkled  and  the  eyes  but  half  opened, 
owing  to  the  contraction  of  the  orbiculares  oculorum.  Shortly  after 
the  advent  of  these  symptoms  the  rigidity  increases,  and  other 
muscles,  especially  those  of  the  trunk,  become  affected.  The 
abdomen  becomes  as  rigid  as  a  board,  owing  to  the  tonic  con- 
traction of  the  recti  abdominis ;  the  trunk  muscles  become  con- 
tracted, and  in  severe  cases  a  more  or  less  marked  condition  of 
opisthotonus  develops,  so  that  the  patient  is  supported  by  his  heels 
and  his  head :  sometimes  also  with  a  lateral  curvature  of  the  spine 
during  the  paroxysms.  It  is  a  marked  characteristic  of  the  disease 
that,  although  the  proximal  muscles  of  the  limbs  may  be  affected, 
those  of  the  hands  and  feet  are  neither  rigid  nor  stiff,  although 
tenderness  and  a  feeling  of  stiffness  in  the  region  of  the  seat  of 
infection  may  be  noticed ;  but  local  spasms  are  generally  so  slight 
as  only  to  be  elicited  by  careful  inquiry,  the  patient's  first  complaint 
being  usually  of  the  condition  of  his  head  or  neck.  When  the 
initial  lesion  has  been  in  the  head  the  symptoms  differ  somewhat ; 
there  is  some  paralysis  as  well  as  rigidity  of  the  facial  muscles,  and 
not  infrequently  there  is  marked  pharyngeal  spasm  ;  such  cases  have 
been  termed  "  cephalic  tetanus." 

To  the  condition  of  tonic  contraction  are  soon  superadded 
paroxysmal  contractions,  which  are  readily  induced  by  the  slightest 
movement  or  even  by  a  breath  of  wind.  These  recur  with  in- 
creasing severity  and  frequency,  and  may  be  so  violent  as  to  lead  to 
rupture  of  muscular  fibres.  Exceptionally  there  may  be  only  tonic 
spasm  or  only  paroxysmal  contractions. 

Pain  is  an  early  symptom,  and  in  severe  cases  it  is  intense,  similar 
to  that  of  cramp  ;  a  very  distressing  pain  behind  the  sternum  is  often 
present,  and  is  probably  the  result  of  spasm  of  the  diaphragm.  If 
the  patient  can  sleep  the  spasm  relaxes,  but  in  severe  cases  this  is 
often  impossible. 

The  temperature  varies ;  in  the  extremely  severe  cases,  with 
frequently  recurring  convulsive  attacks,  it  is  raised  and  may  run  up 
towards  the  end  to  105°  F.  or  higher.  An  analysis  of  the  tempera- 
tures in  a  series  of  cases  shows  that  in  the  more  moderate,  when  it 
is  only  raised  to  102°  or  103°,  there  is  generally  sufficient  local 
suppuration  to  account  for  this  ;  and  that  when  the  initial  seat  of 
infection  is  free  from  inflammation  the  temperature  may  nou  be 
raised.      The  pulse  may  be  rapid  and  is  often  very  small. 

The  urine  is  found  to  be  free  from  albumen,  but  there  is  often 


i6o  MANUAL   OF   MEDICINE 

a  difficulty  in  micturition  owing  to  the  spasms  not  only  of  the 
abdominal  muscles  but  probably  also  of  those  of  the  bladder. 
Constipation  is  common.  The  amount  of  perspiration  is  variable, 
sometimes  it  is  excessive. 

Prognosis. — The  acute  cases,  95  per  cent  of  which  are  fatal, 
seldom  survive  seven  days,  and  death  may  occur  in  twenty-four  to 
thirty-six  hours  from  the  comniencement  of  the  attack.  The  later 
the  onset  of  the  symptoms  the  greater  the  probability  of  the  case 
running  a  subacute  course.  Exceptionally,  however,  patients  have 
died  after  five  or  six  weeks,  and  one  girl  died  five  months  after 
running  a  nail  into  her  foot,  and  four  months  after  the  onset  of 
symptoms,  which  throughout  were  never  very  violent.  Very  few 
of  the  cases  following  parturition  or  occurring  in  new-born  infants 
recover.  If  the  patient  have  survived  ten  days  there  is  a  fair 
prospect  of  ultimate  recovery.  This  is  always  a  very  gradual 
process ;  the  spasmodic  attacks  become  more  infrequent  and  less 
severe,  but  the  tonic  contraction  of  the  muscles  persists  for  a  long 
time,  and  only  passes  off  very  gradually.  The  mortality  of  so-called 
idiopathic  cases  is  about  50  per  cent. 

Modes  of  death. — In  acute  cases  the  patients  may  die  from 
asphyxia  due  to  prolonged  tonic  spasm  of  the  respiratory  muscles, 
which  may  remain  absolutely  fixed  for  more  than  a  minute.  If 
such  attacks  recur,  the  patient  is  almost  certain  to  die  in  one  of 
them,  the  pulse  continuing  after  the  respiration  has  ceased.  In 
other  cases,  the  patient  gradually  dies  from  exhaustion  or  from 
cardiac  failure,  the  intelligence  being  preserved  to  the  last. 

Post-mortem  appearances. — There  are  no  constant  lesions 
to  be  found.  In  a  few  cases  there  has  been  evidence  of  inflamma- 
tion spreading  up  along  the  nerves  from  the  seat  of  injury,  but  in 
many  this  is  absent.  Ecchymoses  and  cell-infiltration  of  the  peri- 
vascular spaces  on  the  surface  of  the  brain  and  in  the  spinal  cord 
have  been  noticed.  Possibly  with  the  modern  methods  of  examina- 
tion, changes  may  be  found  in  the  nerve  cells  of  the  spinal  cord. 

Diagnosis. — Tetanus  has  to  be  distinguished  from  the  following  : 

Strychnine  poisoni?ig. — Here  the  sjaiiptoms  come  on  suddenly, 
within  a  short  period  after  taking  the  poison,  and  two  hours  after 
the  first  spasm  the  patient  is  either  dead  or  is  recovering.  There  are 
violent  convulsive  movements,  which  affect  the  whole  body ;  the 
hands  are  clenched,  but  the  jaws  are  affected  late,  if  at  all.  The 
muscles  are  completely  relaxed  between  the  spasms.  The  patient 
may  die  within  a  few  minutes  of  the  onset  of  the  spasms. 

Hydrophobia, — In  this  malady  the  spasms  are  paroxysmal  and 


TETANUS  t6i 

not  tonic ;  they  mainly  affect  the  muscles  of  deglutition  and  respira- 
tion, and  are  induced  by  attempts  to  drink.  Among  other  distin- 
guishing features  are  the  delusions  and  other  mental  disturbances 
which  are  seldom  or  never  met  with  in  tetanus. 

Cerebro-spinal  meniiigitis. — Tonic  spasms  are  readily  induced 
by  movements ;  but  the  pyrexia,  the  optic  neuritis,  the  vomiting, 
headache  and  stupor,  suffice  to  distinguish. 

Hysteria. — This  may  produce  opisthotonus  and  trismus,  but 
the  other  associated  symptoms  indicate  the  diagnosis.  If  there  is 
only  trismus,  the  onset  is  sudden  and  complete,  and  the  neck  is  not 
stiff. 

Tetany. — The  characteristic  and  tonic  contraction  of  the  fingers 
at  once  differentiate  this. 

Local  mfiammatioii.,  such  as  results  from  impaction  of  a  wisdom 
tooth,  may  prevent  the  jaws  from  being  opened,  but  the  masseters 
are  not  contracted,  nor  are  there  contractions  in  other  muscles. 

Any  suppurating  centre  should  always  be  examined  for  tetanus 
bacilli,  but  they  are  not  always  to  be  discovered,  and  in  any  case  of 
doubt  cultivations  should  be  made,  and  a  drop  of  pus  or  fluid  should 
be  inoculated  into  the  root  of  the  tail  of  a  mouse,  which,  if  infected, 
will  die  within  three  or  four  days  from  tetanus. 

Treatment. — Prophylactic  treatment  is  of  the  greatest  im- 
portance. Since  aseptic  methods  have  come  into  use,  tetanus  has 
become  a  much  rarer  disease  than  formerly.  All  wounds,  especially 
those  which  have  been  contaminated  with  garden  soil  or  manure, 
should  be  thoroughly  cleaned,  and  suppuration  should  be  prevented 
when  possible.  In  any  case  of  tetanus  any  suspicious  abrasion  or 
injury  should  be  thoroughly  scraped  and  examined  under  an 
anaesthetic,  any  foreign  body  removed,  and  any  inflamed  or  sup- 
purating area  excised  when  feasible.  There  is  no  justification,  how- 
ever, for  the  removal  of  a  limb,  solely  on  the  ground  that  it  would 
remove  a  focus  of  infection,  as  this  has  not  led  to  beneficial  results. 
It  has  been  proposed  that  the  wound  should  be  dressed  with  a  ten- 
volume  solution  of  peroxide  of  hydrogen,  and  frequently  bathed  in 
it,  but  it  is  of  even  greater  importance  to  keep  the  wound  aseptic. 

No  more  striking  instance  of  the  value  of  cleanliness  and  of  the 
use  of  antiseptics  in  the  prevention  of  tetanus  could  be  afforded 
than  that  of  its  abolition  in  the  year  1893  from  the  Island  of  St. 
Kilda.  Previously,  84  out  of  125  children,  or  67  per  cent,  had 
died  of  tetanus,  or,  as  it  was  called  locally,  of  the  "eight-day  sick- 
ness." 

Antitoxin. — Tetanus  was  the  first  disease  in  which  the  curative 

VOL.  I  M 


1 62  MANUAL  OF  MEDICINE 

effects  of  the  injection  of  the  serum  of  animals  which  had  been  pre- 
viously rendered  immune  to  the  poison  of  a  disease  was  thoroughly 
investigated.  If  such  serum  be  injected  at  the  same  time,  or  soon 
after,  an  animal  is  inoculated  with  tetanus,  its  prophylactic  effect  is 
marked.  When  the  subcutaneous  injection  of  the  antitoxin  is  delayed 
until  the  onset  of  tonic  spasm,  it  is  quite  unable,  if  the  attack  is 
severe,  to  stay  the  progress  of  the  disease.  The  serum  is  able  to 
protect  nerve  cells  from  afterwards  becoming  affected  by  the  poison, 
but  it  cannot  counteract  the  poison  if  it  have  already  injured  the  cells. 

Within  the  past  year,  however,  it  has  been  shown  by  Roux  and 
Berrel  that  if  the  serum  be  injected  directly  into  the  brain  substance, 
even  after  the  onset  of  symptoms,  it  is  capable  of  terminating  the 
spasms  and  of  inducing  recovery.  Clinical  experience  has  also  already 
led  to  some  remarkable  recoveries  following  this  method  {Brit.  Med. 
Journal^  1899,  i.  pp.  10,  895,  and  1333).  The  procedure,  how- 
ever, is  not  free  from  danger,  since  one  of  these  cases,  when  con- 
valescence was  apparently  fully  established  and  all  symptoms  of 
tetanus  had  disappeared,  died  eight  weeks  after  the  last  intra-cerebral 
injection  from  cerebral  abscess,  although  every  care  had  been  taken 
to  secure  asepsis  at  the  operation  of  drilling  the  skull  and  injecting 
the  serum  {ib.  ii.  p.  9). 

In  a  dubious  case,  before  the  onset  of  definite  symptoms,  the  sub- 
cutaneous injection  of  10  cc.  of  antitoxic  serum,  repeating  this  once 
or  twice  a  day  as  necessary,  will  probably  suffice  to  stay  the  disease. 
Should  the  symptoms  be  fully  developed,  according  to  present  experi- 
ence, it  is  desirable  also  to  trephine  over  each  frontal  eminence,  and 
with  due  aseptic  precautions  slowly  to  inject  into  the  brain  tissue  on 
each  side  5  cc.  of  serum.  The  injections  may  require  to  be  repeated. 
This  will  prevent  the  cerebral  cells  from  fixing  the  poison,  while  the 
subcutaneous  injections  will  neutralise  the  poison  in  the  blood.  Re- 
covery takes  place  slowly  after  a  prolonged  illness. 

The  following  means,  though  powerless  to  save  a  patient's  life 
if  the  attack  is  severe,  are  of  considerable  value  in  the  milder  cases 
in  alleviating  the  symptoms: — 

It  is  most  important  that  the  patient  be  kept  quiet  in  bed  in  a 
darkened  room,  and  carefully  protected  from  every  form  of  irritation. 

Chloral,  if  used,  must  be  given  in  large  doses,  and  frequently 
repeated,  20  to  30  grains  being  indicated,  but  much  larger  doses 
have  often  been  employed.  Morphia,  given  subcutaneously  and  at 
short  intervals,  affords  great  relief.  One-sixth  of  a  grain  of  morphia 
was  given  every  two  hours  for  a  fortnight  to  a  boy  under  the  writer's 
charge,  with   very   great   amelioration   of  the  symptoms,  and  with 


DIPHTHERIA  163 

ultimate  recovery.  Preparations  of  physostigma  in  large  doses, 
bromides,  and  other  sedatives  frequently  repeated,  have  been  used 
with  some  benefit. 

Chloroform  is  required  when  the  spasms  are  very  severe,  and 
when  the  chest  has  been  held  fixed  by  a  profound  spasm.  It  may 
advantageously  be  combined  with  artificial  respiration,  which  is 
preferable  to  tracheotomy  should  the  respiration  cease  from  spas- 
modic fixation  of  the  chest. 

When  there  is  a  difficulty  in  feeding  the  patient,  liquid  food  can 
be  introduced  by  a  soft  tube  passed  behind  the  teeth,  or  through  the 
nostrils,  but  the  passage  of  a  nasal  tube  into  the  oesophagus  generally 
brings  on  an  attack  of  spasm,  so  that  it  may  require  to  be  introduced 
under  an  anaesthetic,  or  rectal  feeding  may  be  resorted  to. 

G.  Newton  Pitt. 


DIPHTHERIA 
Syn.   Membranous  Croup 

The  disease  is  characterised  by  an  exudative,  or  membranous 
inflammation  of  the  faucial,  nasal,  or  respiratory  mucous  membranes, 
more  rarely  of  wound  surfaces ;  attended,  in  severe  cases,  with  pro- 
found constitutional  depression,  and  degenerative  changes  in  certain 
tissues,  notably  the  peripheral  nervous  system,  cardiac  muscle,  and 
renal  parenchyma.  These  changes  result  from  the  absorption  into 
the  circulation  of  toxic  material  elaborated  by  a  specific  bacillus 
which  is  invariably  present  at  the  seat  of  exudation.  The  presence 
of  this  bacillus,  which  was  discovered  by  Klebs  in  1883,  and  sub- 
sequently confirmed  by  Loffler,  is  now  held  to  be  the  only  true 
criterion  of  diphtheria ;  although  the  teaching  of  Bretonneau,  that 
the  presence  of  exudation  was  in  itself  distinctive,  had  until  recent 
years  been  almost  universally  accepted.  ' 

Etiology. — Though  widely  diffused,  it  is  chiefly  in  temperate 
and  cold  damp  climates  that  diphtheria  prevails.  Damp,  low-lying 
districts,  possessing  a  soil  retentive  of  wet,  and  rich  in  decaying 
organic  matter,  usually  show  a  high  fatality  from  diphtheria,  especi- 
ally if  subject  to  the  continued  prevalence  of  cold  winds,  coupled 
with  a  high  rainfall.      In  this  country  the    disease  seems  to  have 


164  MANUAL  OF  MEDICINE 

been  on  the  whole  more  prevalent  in  those  counties  lying  along  the 
east  coast  than  elsewhere.  Like  enteric  and  scarlet  fevers,  the 
greatest  incidence  of  diphtheria  falls  in  the  late  autumn  and  early 
winter,  the  maximum  usually  being  attained  either  in  November  or 
December,  when  the  case  mortality,  too,  is  often  above  the  average. 
The  prevalence  is  usually  at  its  lowest  point  during  the  summer 
months.  It  is  an  interesting  fact  that  in  England,  at  any  rate, 
diphtheria,  though  formerly  more  frequent  in  rural  districts,  has 
during  the  last  twenty  years  shown  a  constantly  increasing  tendency 
to  affect  the  population  of  towns,  though  different  outbursts  are 
characterised  by  considerable  variation  in  severity.  There  are 
good  reasons  for  believing  this  to  be  mainly  dependent  upon  con- 
ditions associated  with  the  extension  of  compulsory  education.  It 
is  now  more  or  less  endemic  in  most  large  towns. 

Our  views  as  to  the  part  played  by  drainage  defects  in  the 
etiology  of  diphtheria  have  undergone  considerable  modification  of 
late.  It  is  now  very  generally  recognised  that  inadequate  drainage 
of  the  surface  soil,  deficient  scavenging,  and  dampness  of  habitation, 
are  influences  far  more  potent  in  the  propagation  of  diphtheria  than 
the  inhalation  of  sewer  gas,  which,  until  recently,  was  universally 
regarded  as  a  common  source  of  direct  infection.  Now,  although 
sewer  gas  can  hardly  be  regarded  as  a  source  of  direct  infection — 
and  it  may  be  remarked  that  the  diphtheria  bacillus  has  never  been 
detected  in  it— there  is  no  doubt  but  that  the  health  of  persons  who 
have  been  for  some  time  living  under  its  influence  may  become 
injuriously  affected.  Their  powers  of  resistance  become  lowered, 
even  if  they  do  not  suffer  from  a  definite  sore  throat,  and  under 
these  circumstances  they  are  prone  to  fall  easy  victims  to  a  chance 
infection,  and  contract  the  disease  in  an  aggravated  form.  Another 
important  factor  in  the  propagation  of  diphtheria  is  school  attend- 
ance. Not  only  does  the  herding  together  of  a  number  of  children 
under  one  roof  for  several  hours  a  day  provide  special  opportunities 
for  the  transmission  of  infection,  but  the  potential  victims  are  of  an 
age  at  which  they  are  very  liable  to  take  diphtheria  when  exposed  to 
it,  and  one,  moreover,  at  which  they  are  very  susceptible  to  the 
noxious  influence  of  overcrowding  and  inadequate  ventilation.  The 
combination  of  the  foregoing  conditions,  known  collectively  as 
"  school  influence"  has  been  shown  by  Sir  Richard  Thorne  Thorne 
to  be  competent  to  bring  about  a  progressive  increase  of  infectivity 
in  a  consecutive  series  of  throat  attacks  ;  so  that  severe,  or  even 
lethal  attacks  of  diphtheria  may  result  from  what  originally  appeared 
to  be  a  trivial  non-specific  sore  throat. 


DIPHTHERIA  165 

Although  the  part  played  by  faulty  sanitation  and  school  influence 
in  the  diffusion  of  diphtheria  is  well  recognised,  the  most  important 
agent  is  undoubtedly  personal  infection.  The  contagium  of  diphtheria 
is  readily  transmissible  by  means  of  minute  particles  of  mucus  or 
flecks  of  membrane,  which  may  be  ejected  from  the  mouth  or  nose 
by  an  act  of  coughing,  sneezing,  or  even  laughing  in  an  explosive 
manner.  The  infective  material  may  either  be  transmitted  directly 
into  the  mouth  or  nose  of  another  person,  or  indirectly,  after  com- 
plete desiccation,  by  means  of  a  current  of  air.  Infection,  too,  may 
result  from  the  act  of  kissing,  or  from  using  the  same  pocket  hand- 
kerchief, cup,  or  spoon.  Milk  is  a  frequent  channel  of  infection. 
In  some  cases,  no  doubt,  it  becomes  accidentally  contaminated  from 
a  human  source.  The  bacillus  grows  well  in  milk ;  in  other  cases, 
according  to  Dr.  Klein,  the  milk  appears  to  derive  its  infective  pro- 
perties from  the  cow  itself,  in  virtue  of  the  animal  being  affected 
with  a  disease  the  counterpart  of  human  diphtheria.  Cats  are  a 
distinct  source  of  danger,  as  they  are  hable  to  contract  true 
diphtheria,  and  thus  transmit  the  disease.  There  is  no  reason  to 
think  that  diphtheria  is  ever  spread  by  means  of  an  infected  water 
supply.  A  person  should  be  regarded  as  a  possible  source  of 
infection  so  long  as  any  diphtheria  bacilli  can  be  detected  in  the 
throat  or  secretions,  nor,  if  practicable,  should  he  be  allowed  to  mix 
with  others  until  the  discharge  from  any  aff'ected  surface  has  ceased. 

Predisposition  to  diphtheria  varies  with  age,  sex,  state  of  health, 
and  previous  attack  The  influence  of  age  and  sex  is  shown  by  the 
table  given  on  next  page,  which  is  compiled  from  the  total  diphtheria 
admissions  into  the  hospitals  of  the  Metropolitan  Asylums  Board 
during  the  ten  years  ending  1897. 

Approximately,  three-fourths  of  the  attacks  were  in  children  under 
ten  years  of  age.  The  same  fact  is  apparent  in  respect  to  scarlet 
fever ;  but  in  that  disease  the  incidence  is  greatest  in  the  second 
quinquennium  of  life,  instead  of  the  first.  One-fifth  more  females 
were  attacked  than  males.  Persons  are  very  liable  to  contract 
diphtheria  who  have  been  recently  subject  to  any  acute  disorder, 
especially  if  attended  with  any  sore  throat  or  nasal  discharge,  such  as 
tonsillitis,  scarlet  fever,  or  measles.  In  this  connection  the  influence 
of  drainage  defects  and  overcrowding  has  been  already  referred  to. 
The  immunity  conferred  by  an  attack  of  diphtheria  lasts  but  three 
or  four  weeks  in  most  persons,  hence  a  relapse  or  definite  second 
attack  is  often  met  with. 

The  period  of  incubation  is  frequently  dii^cult  to  determine, 
because  an  exudation  may  have  been  present  for  several  days  before 


i66 


MANUAL   OF   MEDICINE 


Males. 

Females. 

Total. 

AGES. 

Admitted. 

Died. 

Mortality 

Died. 

Mortality 

Admitted. 

Died. 

Mortality 

per  cent. 

per  cent. 

Under   i   .      . 

239 

"5 

48.1 

196 

103 

52.6 

435 

218 

50.1 

I  to    2 

819 

411 

50.2 

729 

368 

50-5 

1,548 

779 

50-3 

2  „     3 

1,101 

466 

42.3 

1,120 

440 

39-3 

2,221 

906 

40.8 

3  ,.    4 

1,486 

545 

36.7 

1,485 

503 

33-9 

2,971 

1,048 

35-3 

4  „    5  •     • 

Totals  under"! 
5  years  j 

1,423 

432 

30-4 

1,662 

517 

3I-I 

3,085 

949 

30.8 

5,068 

1,969 

38-9 

5,192 

1,931 

37-2 

10,260 

3,900 

38.0 

5  to  lo  .      . 

3>978 

850 

21.4 

4,720 

1,094 

23.2 

8,698 

1,944 

22.3 

lo  ,,  15 

1,205 

no 

8.7 

1,695 

144 

8.5 

2,960 

254 

8.6 

15  ,,  20 

497 

26 

5-2 

817 

34 

4.2 

1,314 

60 

4.6 

20  ,,25 

297 

14 

4-7 

562 

20 

3-6 

859 

34 

4.0 

25  „  30 

182 

12 

6.6 

405 

13 

3-2 

5S7 

25 

4-3 

30  „  35 

119 

4 

3-4 

222 

14 

6.3 

341 

18 

5-3 

35  >>  40 

67 

4 

6.0 

118 

5 

4.2 

185 

9 

4.9 

40  ,,  45 

37 

3 

X                          /■ 

58 

5 

-12.3-' 

95 

8 

■  13-3 

45  »  50 

19 

I 

34 

4 

53 

5 

50  „  55 

15 

4 

-15.0  J 

14 

2 

29 

6 

55  .,  60 

6 

2 

15 

I 

21 

And  upwards 

3 

2 

9 

4 

V 

12 

6 

J 

Grand  To 

tals 

ii>553 

3,001 

26.0 

13,861 

3,271 

23.6 

25,414 

6,272 

24.7 

attention  is  called  to  the  throat.  Symptoms  of  invasion  often  appear 
within  thirty-six  hours  of  infection,  and  though  they  are  rarely  delayed 
more  than  four  or  five  days,  a  quarantine  of  ten  or  twelve  days 
should  be  maintained. 

For  the  purposes  of  clinical  description,  attacks  of  diphtheria 
may  be  conveniently  divided  into  the  five  following  groups  : — 

I.  Mild  Fa  ucial  Form. — This  class  of  case  is  most  common 
in  adults,  and,  except  for  the  presence  of  exudation,  there  is  little  to 
distinguish  it  from  an  attack  of  simple  tonsillitis.  The  exudation  is 
usually  limited  to  the  tonsils,  which  are  more  or  less  swollen,  one 
commonly  more  than  the  other ;  but  a  patch  may  form  on  the  con- 
tiguous side  of  the  uvula.  The  exudation  usually  takes  the  form  of 
a  thin,  fibrinous,  or  cheesy-looking  pellicle,  of  a  dead  white  or  grayish 
tint,  lying  on  the  surface  of  the  tonsil,  to  which  it  is  loosely  adherent. 
In   other   cases  the   exudation   occurs   in  one  or    more    depressed 


DIPHTHERIA  167 

patches,  with  clearly-defined  margin,  resembling  a  shallow  necrotic 
ulceration  of  the  tonsils,  which,  like  the  surrounding  mucous  mem- 
brane, are  red  and  angry-looking.  The  subjacent  glandular  swelling 
corresponds  to  the  extent  to  which  the  tonsil  on  that  side  is  in- 
volved. The  pyrexia  usually  ranges  from  101°  to  103°,  its  degree 
being  proportionate  to  amount  of  faucial  inflammation,  and  slight 
albuminuria  is  common.  After  three  or  four  days'  appropriate  treat- 
ment the  exudation  commonly  clears,  and  the  patient  is  convalescent 
by  the  end  of  a  week  or  ten  days. 

11.  Severe  Faucial  Form,  tisually  showing  a  tendency  to 
extension. — This  is  most  common  in  young  children,  in  whom  the 
mortality  is  very  high.  The  disease  affects  the  fauces  primarily,  and 
from  thence  may  spread  to  the  pharynx,  nares,  or  respiratory  pas- 
sages. The  symptoms  of  invasion  are  in  most  cases  pronounced ; 
but  in  some  patients  the  attack  represents  a  progressive  development 
of  one  w^hich  originally  bid  fair  to  run  a  mild  course.  For  this 
reason  no  attack  of  diphtheria  in  a  young  child,  however  mild,  should 
ever  be  lightly  regarded.  The  onset  is  usually  attended  with  shiver- 
ing, pain  in  swallowing,  and  not  infrequently  vomiting,  in  addition 
to  the  usual  signs  of  febrile  invasion.  The  tonsils  are  much  swollen 
at  an  early  stage,  and  may  almost  meet  in  the  mid-line  so  as  to 
partially  obscure  the  uvula,  which  is  usually  oedematous.  Their  surface 
is  covered  with  thick  white  exudation,  presenting  either  a  glistening 
or  dead-white  appearance  like  that  of  wash-leather,  and  the  faucial 
mucous  membrane  generally  is  usually  of  a  pinkish  rather  than  deep 
red  colour,  and  slippery-looking,  owing  to  the  presence  of  much 
glairy  mucus.  The  uvula  is  sometimes  ensheathed  with  a  coat  of 
membrane,  like  the  finger  of  a  glove,  and  patches  of  exudation  are 
often  present  on  the  soft  palate  and  anterior  pillars  of  the  fauces. 
There  is  usually  considerable  infiltration  of  the  subjacent  glands  and 
connective  tissue,  and  a  muco-purulent  or  thin  straw-coloured  dis- 
charge may  escape  from  the  nostrils,  in  consequence  of  the  nasal 
fossse  having  become  involved  in  the  disease.  The  tongue  is  coated 
with  a  pasty  fur,  and  the  temperature  during  the  first  three  or  four 
days  is  raised,  perhaps,  to  103°  or  more ;  but  under  the  influence  of 
efficient  local  treatment,  apart  from  the  efi"ect  of  antitoxin,  a  rapid 
fall  commonly  occurs,  even  before  the  condition  of  the  fauces  shows 
a  corresponding  improvement.  Diphtheria  has  no  typical  tempera- 
ture curve,  the  worst  cases  often  having  a  normal  temperature  almost 
from  the  commencement.  The  patient's  condition  becomes  one 
of  great  distress,  in  consequence  of  the  acute  pain  which  constantly 
attends  the  act  of  swallowing  food  and  saliva.      His  distress  is  in- 


1 68  MANUAL  OF  MEDICINE 

creased  by  reason  of  the  nasal  passages  being  more  or  less  blocked ; 
and  should  the  disease  extend  to  the  larynx,  the  horrors  of  croup  are 
superadded.  Epistaxis,  or  bleeding  from  the  margin  of  the  faucial 
exudation,  may  occur  at  this  stage,  and  the  urine  is  usually  albumin- 
ous. As  the  case  proceeds  the  exudation  becomes  discoloured, 
owing  to  putrefactive  changes,  and  is  gradually  thrown  off,  perhaps 
to  be  replaced  by  a  fresh  deposit.  If  forcibly  removed,  a  bleeding 
and  excoriated  surface  remains. 

Should  the  patient  survive,  the  general  swelling  of  the  parts 
undergoes  considerable  abatement  by  the  end  of  the  week,  or  a  few 
days  later,  though  the  pulse  at  this  stage  may  show  distinct  evidence 
of  weakness.  A  superficial  ulceration  remains  after  the  membrane 
has  become  detached.  This  soon  heals,  and  the  faucial  discomfort 
then  disappears. 

Now,  it  by  no  means  follows  that  recovery  will  ensue,  although 
the  patient  may  have  progressed  to  the  above  extent.  Nothing 
could  be  more  fallacious ;  for  the  second  week  of  diphtheria, 
especially  its  latter  half,  is  the  time  when  the  most  fatal  develop- 
ment to  which  the  patient  is  liable,  viz.  "cardiac  failure,"  is  most 
likely  to  arise,  though  it  may  not  appear  until  a  week  or  two  later. 
The  onset  of  cardiac  failure  is  characterised  by  progressive  enfeeble- 
ment  of  the  circulation,  and  often,  though  by  no  means  necessarily, 
there  is  marked  dilatation  of  the  left  ventricle.  The  pulse  becomes 
unduly  slow,  or  irregular,  and,  though  in  some  cases  its  rapidity  is 
increased,  its  tension  is  always  diminished.  Incessant  vomiting, 
increasing  pallor,  combined  with  restlessness,  and  sighing,  or  irregular 
respiration,  are  constant  features.  Acute  pain  in  the  epigastric  or 
precordial  region  is  often  present,  and  distressing  cramps  in  the 
muscles  of  the  back  and  limbs  are  sometimes  complained  of.  The 
temperature  becomes  subnormal,  much  albumin  appears  in  the 
urine,  which  is  scanty ;  or  it  may  be  entirely  suppressed  for  twenty- 
four  hours  or  more  before  death.  Coldness  of  the  extremities 
gradually  supervenes,  the  collapse  becomes  more  profound,  and  life 
slowly  ebbs  away,  the  patient  usually  retaining  consciousness  to  the 
end.  The  victim  sometimes  lingers  on  for  several  days,  but  a 
sudden  syncopic  attack  usually  terminates  the  scene. 

In  the  very  worst,  the  so-called  "  malignant,"  attacks,  the  whole 
of  the  faucial  structures  become  rapidly  covered  with  a  thick  sheet 
of  gelatinous  membrane  which  often  encroaches  on  the  hard  palate 
and  buccal  surface  of  the  cheek.  The  nares,  too,  are  blocked,  and 
a  thin  blood-stained  fluid  exudes  from  the  nostrils.  There  is  much 
swelling  of  the  neck,  and  the  patient,  quite  unable  to  swallow,  dies 


DIPHTHERIA  169 

from  cardiac  failure  before  the  end  of  the  week.  The  toxaemic 
character  of  such  an  attack  is  evidenced  by  the  waxy  pallor  of  the 
skin,  which  is  early  apparent,  the  cyanotic  appearance  of  the  lips, 
the  staining  which  is  seen  to  follow  the  course  of  many  of  the 
superficial  veins,  the  lowness  of  the  temperature,  the  cardiac  de- 
pression, and  the  liability  to  some  form  of  hemorrhage.  This 
may  occur  from  any  of  the  mucous  surfaces  —  fauces,  nares,  gums, 
conjunctivae,  stomach,  intestines,  genito-urinary  passages,  or  into  the 
tissue  of  the  skin.  Bruising  may  result  from  the  slightest  pressure, 
or  the  most  insignificant  contusion,  and  is  well  marked  round  the 
site  of  a  hypodermic  injection.  Hsemorrhagic  attacks  are  seemingly 
always  fatal.  Death  usually  occurs  during  the  course  of  the  second 
week,  but  in  the  worst  cases  may  take  place  earlier. 

III.  Laryngeal  Form. — The  air  passages  may  be  affected 
primarily,  sometimes  exclusively ;  but  croup  more  often  arises  as  a 
complication  of  faucial  diphtheria,  which,  if  mild,  may  have  pre- 
viously escaped  observation.  The  term  "  croup  "  denotes  a  condi- 
tion of  laryngeal  obstruction,  whether  membranous,  as  in  diphtheria, 
or  not.  Its  onset  is  characterised  by  the  gradual  development  of 
hoarseness,  with  an  ineffectual,  metallic  cough,  and  ultimately  com- 
plete aphonia.  After  from  twelve  to  thirty-six  hours  the  laryngeal 
affection  usually  becomes  sufficiently  pronounced  to  be  a  source  of 
actual  dyspnoea.  The  breathing  is  stridulous,  the  child  becomes 
restless,  and  is  in  constant  terror  of  suffocation.  Marked  recession 
of  the  soft  parts  of  the  thoracic  walls  as  well  as  of  the  lower  ribs 
and  epigastrium  on  inspiration  is  then  apparent ;  expiration  becomes 
attended  with  distinct  muscular  effort  ;  cyanosis  and  drowsiness 
gradually  supervene,  and  the  child  dies  suffocated,  unless  relieved 
by  operation.  The  membrane,  meanwhile,  usually  spreads  down 
the  trachea  into  the  bronchial  tubes,  often  to  their  smallest  ramifi- 
cations. In  favourable  cases  the  laryngeal  swelling  subsides  in  a 
few  days,  more  or  less  complete  casts  of  the  trachea  and  bronchi 
being  at  times  expelled,  arid  convalescence  advances  rapidly. 
Diphtheria,  when  limited  to  the  air  passages,  is  rarely  followed  by 
cardiac  failure  or  paralysis.  Primary  laryngeal  diphtheria  is  seldom 
seen  in  adults,  and  although  extension  to  the  larynx  occurs  in  them 
occasionally,  it  rarely  gives  rise  to  obstructive  dyspnoea.  It  may 
prove  fatal,  however,  by  spreading  to  the  smaller  air  passages. 

IV.  Nasal  Form.  —  The  nasal  passages  are  frequently  in- 
volved in  severe  faucial  attacks,  consequently  nasal  diphtheria  is 
generally  regarded  as  a  grave  condition.  Pure  nasal  diphtheria, 
however,  is  commonly  a  mild  development,  and  occurs  more  often 


I70  MANUAL  OF  MEDICINE 

than  is  usually  supposed.  Frequently,  the  only  indications  of  its 
presence  are — a  thin  mucoid  rhinorrhoea,  containing  numerous 
diphtheria  bacilli,  slight  soreness  of  the  external  nares,  and  some 
tenderness  of  the  superficial  lymphatic  glands  beneath  the  jaw. 
Occasionally  shreds  of  membrane,  or  incomplete  casts  of  the  nasal 
fossae  are  expelled.  In  rare  instances  the  condition  becomes  more 
or  less  chronic  (rhinitis  fibrinosa),  and  the  patient  continues  to 
expel  casts,  often  of  the  inferior  turbinated  bone,  every  few  days  for 
several  weeks,  or  even  months,  though  his  general  health  remains 
unaffected.  The  importance  of  the  condition,  however,  from  the 
point  of  infectivity  must  not  be  overlooked. 

V.  Other  Forms.  —  Diphtheritic  exudation  sometimes  occurs 
on  the  mucous  membrane  of  other  parts,  viz.  the  cheeks,  gums, 
tongue,  lips,  conjunctivae,  the  external  genitalia,  especially  in  females, 
and  on  the  surface  of  open  wounds.  The  condition  is  usually 
associated  with  either  faucial,  nasal,  or  laryngeal  diphtheria ;  but  in 
the  case  of  open  wounds  is,  perhaps,  more  often  primary.  The 
gravity  of  the  condition  is  proportionate  to  the  amount  of  surface 
involved.  Most  cases  of  extensive  wound  diphtheria  are  fatal 
through  cardiac  failure. 

Of  the  complications  liable  to  supervene,  the  following  list 
shows  the  percentage  incidence  amongst  16,360  attacks  of  diph- 
theria : — 


Albuminuria  . 

40.8  per  cent 

Paralysis 

■      19-1 

Broncho-pneumonia 

2.2 

Relapse 

1.6 

Nephritis 

.88     „ 

Albuminuria  should  be  regarded  as  a  symptom  rather  than  a 
complication  of  diphtheria.  It  is  present  in  more  than  half  the 
number  of  severe  attacks,  and  is  often  excessive.  It  usually  arises 
towards  the  end  of  the  first  week,  or  early  in  the  second,  and,  as  a 
rule,  disappears  shortly  after  the  throat  is  clear.  Though  some- 
times persistent  for  several  weeks,  it  does  not  imply  any  serious 
lesion  of  the  kidneys. 

Paralysis  of  diphtheritic  origin  varies  widely  both  in  its  distribu- 
tion and  degree.  It  is  rarely  complete,  and  is  usually  attended 
with  more  or  less  sensory  disturbance.  It  is  far  more  common 
after  severe  attacks  than  mild  ones.  Indeed,  so  true  is  this  relation, 
that  the  chance  of  subsequent  paralysis  may  usually  be  gauged  by 
the   character,  extent,  and  persistence   of  the  previous   exudation. 


DIPHTHERIA  171 

An  exception,  however,  must  be  claimed  in  respect  to  larjmgeal,  and 
pure  nasal  diphtheria,  which  are  rarely  followed  by  definite,  much 
less  extensive,  paralysis  ;  and  in  rare  instances  a  mild  faucial 
attack  is  followed  by  widespread  palsy.  The  paralysis  affects  young 
children  more  often  than  older  patients,  and  most  frequently  arises 
during  the  second,  third,  and,  more  rarely,  the  fourth  week  of  illness, 
though  it  may  appear  as  late  as  the  sixth  or  seventh  week  in 
exceptional  instances.  The  part  most  often,  and,  usually,  earliest 
affected  is  the  palate.  The  velum  is  seen  to  lie  motionless,  and  its 
natural  arch  appears  somewhat  flattened.  Its  sensibility  is  im- 
paired, and  its  reflex  excitability  lost.  The  voice,  consequently, 
assumes  a  nasal  quality,  and  the  act  of  swallowing  results  in  the 
passage  of  food  into  the  nasal  cavities.  The  ciliary  muscle,  next 
to  the  palate,  is  most  likely  to  suffer,  resulting  in  failure  of  accom- 
modation for  near  vision,  and  consequent  inability  to  read.  Oculo- 
motor paralysis  also  occurs,  though  less  often,  causing  diplopia  and 
strabismus,  the  external  rectus  being  most  often  affected.  It  is 
frequently  bilateral.  Complete  ptosis  is  rare,  but  a  partial  weakness 
of  the  levatores  palpebrEe  can  often  be  detected,  which  gives  the 
patient  a  sleepy  expression.  Next  to  the  palate  and  eyes,  the  legs 
most  frequently  suffer.  Sensory  disturbance  usually  appears  first 
in  the  form  of  tingling,  or  "  pins  and  needles  "  in  the  feet ;  or  a 
sensation  of  cotton-wool  under  the  soles,  combined  with  numbness, 
or  actual  anaesthesia.  This  may  spread  up  the  legs,  even  to  the 
thighs,  and  is  almost  invariably  combined  with  loss  of  patellar 
reflex.  More  or  less  muscular  weakness  in  the  legs  is  usually 
present,  but  rarely  complete  paralysis.  A  loss  of  patellar  reflex  may 
occur  apart  from  any  indication  of  paralysis  or  anEesthesia. 

In  exceptional  cases  the  arms  are  affected,  or  the  muscles  of  the 
neck  and  trunk,  the  patient  being  then  unable  to  sit  up  in  bed  or 
support  the  weight  of  his  head.  The  diaphragm,  or  the  intercostal 
muscles  may  become  paralysed,  both  of  which  are  a  source  of  urgent 
danger.  In  extreme  cases  anaesthesia  of  the  tongue  and  buccal  sur- 
face may  occur,  and  even  blunting  of  the  sense  of  smell  and  of 
taste.  The  sphincters  are  unaffected  throughout.  Considerable 
wasting  of  the  affected  muscles  sometimes  occurs,  in  degree  pro- 
portionate to  the  duration  of  the  paralysis.  Although  in  the  large 
proportion  of  cases  recovery  takes  place  in  a  few  weeks,  it  may  be 
several  months,  or  even  several  years,  before  complete  restoration 
to  health  is  attained. 

After  severe  attacks  of  diphtheria  a  group  of  paralytic  symptoms 
of  far  greater  gravity  than  the  foregoing  is  liable  to  arise.      During 


172  MANUAL  OF  MEDICINE 

early  convalescence  the  paralysis  of  the  palate  may  become  attended 
with  paralysis  of  the  pharyngeal  constrictors,  with  the  result  that 
deglutition  is  rendered  impossible.  The  arytseno-epiglottidean 
muscles,  and  the  adductors  of  the  larynx  are  usually  affected  as 
well,  and  the  larynx  becomes  anaesthetic.  The  patient  is  con- 
sequently liable  to  be  choked  by  the  passage  of  food  into  the 
trachea,  or  to  be  carried  off  by  septic  broncho-pneumonia.  Vomit- 
ing, cardiac  depression  or  irregularity,  and  sudden  albuminuria  are 
often  superadded.  These  may  be  the  result,  no  doubt,  of  cardiac 
failure  ;  but  their  association  with  the  above  paralytic  manifestations, 
and  the  fact  that  recovery  sometimes  ensues,  are  strongly  suggestive 
that  some  temporary  disturbance  of  the  functions  of  the  vagus 
nerve,  rather  than  myocardial  degeneration,  is  responsible  for  their 
production. 

Broncho-p7ieumonia  in  some  degree  is  probably  more  common 
than  the  above  record  would  seem  to  imply.  Patches  can  almost 
invariably  be  found  in  fatal  cases  of  laryngeal  diphtheria,  though  it 
may  have  been  impossible  to  detect  them  during  life. 

A  relapse  or  recrudescence  of  the  disease  is  liable  to  occur  at 
any  time  after  the  third  week,  especially  in  cases  treated  with  anti- 
toxin.     It  is  almost  invariably  milder  than  the  original  attack. 

Nephritis  is  very  uncommon.  Though  renal  casts  are  present 
in  all  cases,  hsematuria  is  rare.  The  attack  otherwise  presents  no 
special  features  and  the  patient  usually  recovers. 

The  susceptibility  of  the  diphtheria  patient  to  the  infection  of 
scarlet  fever  must  not  be  forgotten. 

Prognosis. — The  death-rate  in  different  epidemics  of  diphtheria 
is  very  variable.  It  is  mainly  influenced  by  the  relative  proportion 
of  young  children  amongst  those  attacked,  and  the  hygienic  con- 
ditions under  which  they  live. 

The  case  mortality  amongst  the  25,414  cases  tabulated  on  page 
166  was  24.7  per  cent,  but  under  the  influence  of  the  antitoxin 
treatment  (commenced  in  December  1894)  the  fatality  in  the 
hospitals  of  the  Asylums  Board  has  been  reduced  from  over  30  per 
cent  to  about  15. 

The  most  important  factors  in  prognosis  are — 

I.  Character  of  attack. — In  laryngeal  cases  the  prognosis  is  always 
grave,  especially  if  secondary  to  previous  faucial  affection.  In  faucial 
attacks  important  indications  are  yielded  by  the  extent,  persistence, 
and  character  of  the  exudation.  In  proportion  as  the  disease  has 
spread  from  the  tonsils  on  to  the  palate,  uvula,  pharynx,  or  into 
the  nasal  fossae,  the  gravity  of  the  attack  will  be  greater,  because  a 


DIPHTHERIA  173 

larger  surface  is  concerned  in  producing  the  toxin.  So,  too,  if  the 
exudation  be  unduly  persistent,  more  toxin  is  produced,  and  relatively 
more  absorbed.  If  an  extensive  membrane  remain  attached  for  five 
or  six  days  the  case  at  once  assumes  a  serious  aspect ;  if  for  two  or 
three  days  longer,  the  prognosis  becomes  exceedingly  grave.  The 
prognostic  significance  of  extent  and  persistence  of  membrane  must 
necessarily  be  relative.  The  most  virulent  type  of  membrane  is 
one  which  is  thick  and  gelatinous,  or  sometimes  distinctly  fibrous 
in  appearance,  and  attended  with  marked  cedema  of  the  mucous 
membrane.  The  least  virulent  is  thin  and  friable,  or  of  cheesy 
consistence,  with  well-defined  margin,  and  little,  if  at  all,  raised 
above  the  surface.  Between  them  all  gradations  occur.  In  thick 
adherent  membranes,  putrefaction  occurs  ^>^  situ ;  hence,  fetor  of 
the  breath  is  a  bad  sign.  Extensive  infiltration  of  the  deep  cervical 
glands  and  connective  tissue  implies  virulence  of  the  local  process. 
A  normal  or  subnormal  temperature,  coupled  with  a  feeble  or  rapid 
pulse,  is  indicative  of  toxaemia ;  and  waxy  pallor  of  the  complexion, 
and  the  sudden  onset  of  severe  albuminuria  is  evidence  in  the  same 
direction.  Haemorrhage  from  a  mucous  surface  is  usually  a  fatal 
sign,  and  the  writer  has  never  seen  a  patient  recover  in  whom  pur- 
puric spots  were  observed  in  the  skin. 

2.  Age. — The  enormous  influence  on  fatality  exerted  by  age  is 
well  shown  by  the  foregoing  table  (page  166).  Age  exerts  a  two- 
fold influence.  Not  only  are  young  children  bad  subjects  for 
diphtheria,  but  in  them  the  disease  shows  a  greater  tendency  to 
assume  the  laryngeal  and  nasal  forms. 

3.  Sex  has  less  influence.  The  mortality  amongst  males  in  the 
foregoing  series  was  26.0  per  cent;  whereas  in  females  it  was  23.6 
per  cent. 

4.  State  of  health. — Those  who  are  subject  to  any  wasting 
disease,  or  who  are  cachectic  in  virtue  of  ill-nutrition  or  a  tuberculous 
dyscrasia  are  prone  to  severe  attacks.  So  also  are  those  who  are 
actually  suff"ering  from  other  acute  infectious  disease,  particularly 
measles,  whooping-cough,  and  scarlet  fever,  as  the  malady  then 
usually  affects  the  respiratory  passages.  The  mortality  of  co-existent 
measles  and  diphtheria  in  pre-antitoxin  days  was  over  80  per  cent. 

5.  Length  of  time  before  coining  under  treattnent. — The  import- 
ance of  early  treatment  has  always  been  recognised  in  respect  to 
local  remedies,  but  it  assumes  a  paramount  importance  in  the  case 
of  treatment  by  antitoxin.  A  procrastination  of  twenty-four  hours 
in  one's  determination  to  give  antitoxin  may  make  just  the  difference 
between  life  and  death  in  a  young  child.      In  laryngeal  attacks  the 


174  MANUAL  OF   MEDICINE 

necessity  for  tracheotomy  is  often  averted,  and  in  faucial  cases  its 
importance  is  nearly  as  great. 

Bacteriology  and  pathology.  —  Tlie  specific  contagium  of 
diphtheria,  the  Klebs-Loffler  bacillus,  is  always  present  in  the  exuda- 
tion, and  in  the  superficial  layers  of  the  affected  mucous  membrane. 
Its  local  multiplication  is  attended  with  the  formation  of  a  specific 
toxin,  which  is  absorbed  into  the  circulation,  and,  by  its  noxious 
effects  on  certain  tissues,  is  productive  of  the  particular  symptoms  of 
the  disease.  Diphtheria,  then,  like  tetanus,  is  an  intoxicative  rather 
than  a  truly  infective  disease,  in  which  the  blood  becomes  infested 
with  the  micro-organisms  themselves.  Recent  research,  however,  has 
shown  that  this  limitation  of  the  bacilli  to  the  local  lesion  is  not 
absolute ;  for  in  severe  attacks  they  have  been  found,  not  only  in 
the  subjacent  lymphatic  glands,  but  in  the  tissue  of  the  lungs,  the 
spleen,  and  more  rarely  the  kidneys.  The  fact  is,  nevertheless, 
beyond  dispute  that  diphtheria  is  primarily,  if  not  essentially,  a 
local  infection.  The  toxin  of  a  virulent  culture  of  the  bacillus 
proves  lethal  to  rabbits  and  guinea  pigs  injected  with  it,  and  tissue 
changes  are  produced  in  them  similar  to  those  found  in  fatal  cases 
of  human  diphtheria.  As  to  its  chemical  nature,  it  has  been 
variously  held  to  be  an  enzyme,  a  toxalbumin,  and  an  albumose. 

The  Klebs-Lofiler  bacillus  is  polymorphic  and  varies  in  length 
from  2  to  6  /A.  It  is  not  motile  and  does  not  form  spores.  It  is 
frequently  somewhat  curved,  though  more  often  straight,  and 
commonly  shows  a  slight  swelling  of  one  or  both  ends  (Plate  I.). 
It  stains  irregularly,  and  consequently  often  presents  a  beaded 
appearance,  or  looks  as  if  segmented.  When  alkaline  methylene 
blue  is  used,  the  irregularity  of  the  staining  is  most  apparent ;  so 
much  so  that  a  dark  dot  may  usually  be  observed  at  each  pole  of  the 
bacillus,  an  appearance  which  is  often  well  brought  out  by  Gramm's 
method.  This  efi"ect  is  commonly  more  pronounced  in  bacilli 
taken  from  a  culture  than  in  those  removed  directly  from  the  throat. 
Two  chief  varieties  of  the  bacillus  are  recognised,  the  long  form  and 
the  short.  The  former  is  much  more  distinctive  than  the  latter, 
the  identification  of  which  is  sometimes  very  difficult.  In  old 
cultures  there  is  a  tendency  for  the  bacilli  to  become  club-shaped 
or  pyriform,  one  end  being  much  swollen,  the  other  tapering  off  to 
a  fine  point.  Clubbing,  however,  is  sometimes  seen  in  newly- 
formed  colonies.  Although  considerable  variation  may  be  noted 
in  respect  to  the  form  and  size  of  individual  bacilli,  their  mutual 
arrangement  in  the  microscopic  field  is  often  very  characteristic, 
being  frequently  aggregated  into  small  clusters,  some  of  the  members 


DIPHTHERIA  175 

of  which  He  parallel  to  each  other,  whilst  others  are  disposed  at 
various  angles  ;  the  general  appearance  of  the  group  thus  resembling 
that  of  a  Chinese  alphabetical  character. 

The  colonies  grow  on  blood-serum  at  37°  C,  can  be  recognised  by 
the  naked  eye  in  twelve  to  sixteen  hours  as  slightly  raised,  round, 
grayish-white  dots,  and  at  the  end  of  twenty-four  hours  are  usually  as 
large  as  a  fair-sized  pin's  head.  On  glycerine-agar  at  the  same  tem- 
perature they  grow  somewhat  less  rapidly,  and  the  colonies  are  slightly 
grayer  and  more  translucent  at  their  periphery  than  in  the  centre. 
On  nutrient  gelatine  at  room  temperatures,  the  growth,  though  far 
slower,  is  more  characteristic.  The  colonies  tend  to  become  faintly 
yellow  in  tint,  their  centres  raised,  and  surrounded  by  concentric  rings, 
which  give  them  a  ripple-like  appearance,  though  this  is  not  very 
obvious  until  after  a  week  or  ten  days'  growth.  No  liquefaction  of  the 
gelatine  takes  place.  When  the  bacillus  is  grown  in  broth  the  medium 
soon  becomes  turbid,  and  deposits  a  white  chalky  sediment  on  the 
bottom  and  sides  of  the  tube. 

Bacilli  are  frequently  found  in  the  throat,  either  alone  or  in 
association  with  the  true  diphtheria  bacillus,  which,  both  morpho- 
logically and  in  their  cultural  behaviour,  are  indistinguishable  from 
it,  but  differ  in  that  they  are  quite  devoid  of  virulence.  Apart 
from  any  difficulty  in  respect  to  the  identification  of  these  pseudo- 
diphtheritic  bacilli,  there  is  considerable  difference  of  opinion 
amongst  bacteriologists  as  to  whether  they  are  true  diphtheria 
bacilli  which  have  become  attenuated,  or  whether  they  should  be 
more  properly  regarded  as  members  of  an  entirely  distinct  species. 
This  point  is  by  no  means  conclusively  settled.  The  local  re- 
action resulting  from  the  multiplication  of  the  bacillus  of  diph- 
theria on  the  surface  of  a  mucous  membrane  constitutes  the  lesion 
which  is  so  distinctive  of  the  disease.  It  is  essentially  an  inflam- 
mation, characterised  by  hyperaemia,  stasis,  the  accumulation  of 
leucocytes,  proliferation,  followed  by  necrosis,  of  the  epithelial  cells, 
and  the  exudation  between  them,  and  on  their  surface,  of  more  or 
less  fibrin.  This  either  takes  the  form  of  a  thin,  loosely-coherent 
pellicle,  or,  should  the  epithelial  layers  be  involved  to  a  greater 
depth,  of  a  thick  tenacious  membrane,  in  which  distinct  evidence  of 
lamination  can  be  made  out.  In  diphtheritic  croup  membrane 
is  found  lining  the  trachea  and  bronchial  tubes,  in  severe  cases, 
even  to  their  smallest  ramifications,  where  it  becomes  lost  in  a  layer 
of  muco-pus.  More  or  less  broncho-pneumonia  is  always  present, 
usually  of  a  truly  diphtheritic  nature,  the  alveoli  being  stuffed  with 


176  MANUAL   OF   MEDICINE 

fibrin,  leucocytes,  and  bacilli ;  or  it  may  be  of  a  septic  order,  due  to 
pyococcal  infection.  The  common  pyogenetic  and  putrefactive 
organisms  may  be  detected  in  the  surface  of  the  exudation  in  practi- 
cally all  cases  of  diphtheria ;  but  in  some  instances  a  definite  septic 
invasion  takes  place.  These  cases  of  "  mixed  infection  "  are  almost 
invariably  severe. 

Post-mortem  appearances.  —  The  appearances  yielded  by 
the  organs  in  fatal  diphtheria  are  not  very  distinctive.  In  severe 
faucial  cases  the  spleen  is  often  somewhat  enlarged,  and  the  same 
is  true  of  the  kidneys,  of  which  the  cortex  is  broader  and  paler 
than  normal,  while  the  epithelial  cells  lining  the  tubules  usually 
show  considerable  fatty  change.  The  heart  muscle  is  pale,  and 
its  component  fibres  to  a  variable  extent  will  be  found  to  have 
undergone  fatty  or  granular  degeneration,  particularly,  though  not 
necessarily,  in  cases  fatal  through  sudden  cardiac  failure.  The 
change  may  be  well  marked  as  early  as  the  fourth  or  fifth  day  of 
the  disease.  The  cardiac  cavities,  especially  the  left  ventricle, 
are  often  markedly  dilated.  It  is  on  nerv-e  tissue,  however, 
that  the  most  distinctive  effects  of  the  diphtherial  poison  are  seen. 
Irregular  foci  of  acute  parenchymatous  degeneration  are  found 
scattered  haphazard  throughout  the  peripheral  nerves,  and,  in  less 
characteristic  degree,  in  the  sympathetic.  The  change  affects 
certain  fibres  alone  in  a  particular  ner\-e,  the  others  being  spared  ; 
and  since  in  a  mixed  nerve  separate  fibres  to  muscles,  and  points 
in  the  skin  to  which  the  degenerated  fibres  run  are  alone  affected, 
not  only  does  paresis  of  the  muscle,  rather  than  paralysis,  result, 
but  the  distribution  of  the  wasting  and  ansesthesia  is  necessarily 
irregular. 

The  differential  diagnosis  between  diphtheria  and  certain 
cases  of  non-specific  inflammation  of  the  faucial,  nasal,  and 
laryngeal  passages  which  simulate  it  is  often  extremely  difficult, 
especially  in  respect  to  follicular  tonsillitis.  It  practically  resolves 
itself  at  the  present  day  into  whether  or  not  the  Klebs-Lofifler 
bacillus  can  be  detected  in  the  exudation  or  discharges.  The  test, 
however,  valuable  though  it  is,  is  unfortunately  not  infallible.  In 
most  cases  bacilli  disappear  in  three  or  four  weeks,  but  they  may 
persist  for  several  months  after  the  throat  has  recovered,  and  are 
even  occasionally  found  in  the  fauces  and  nasal  discharge  of  per- 
fectly healthy  persons,  especially  those  who  have  been  in  attendance 
on  patients  suffering  from  the  disease.  Although,  for  this  reason, 
it  is  impracticable  to  strictly  regulate  the  duration  of  a  patient's 
isolation  by  the  fact  of  the  presence  or  absence  of  the  bacillus,  its 


DIPHTHERIA  177 

value  as  evidence  as  to  the  specific  character  of  an  inflamed  throat 
cannot  be  denied. 

Treatment. — Although  nothing  can  compare  with  the  injection 
of  antitoxic  serum  in  the  treatment  of  diphtheria,  representing,  as  it 
does,  a  true  specific  for  the  disease,  the  simultaneous  adojjtion  of 
efficient  local  treatment  should  not  be  omitted.  This  is  best 
effected  by  syringing  out  the  pharynx,  and,  if  necessary,  the  nasal 
passages,  every  two,  three,  or  four  hours  with  some  antiseptic  and 
astringent  solution  in  the  manner  described  in  the  treatment  of 
septic  attacks  of  scarlet  fever.  By  this  means  the  local  multiplica- 
tion of  the  diphtheria  bacillus,  and  other  micro-organisms,  is  to 
some  extent  inhibited,  and  offensive  secretions  are  cleared  away. 
A  solution  of  chlorine,  or  one  of  formalin  (i  in  200),  or  chinosol 
(i  in  600)  is  the  best.  The  throat  may  be  sprayed  occasionally 
with  a  weak  solution  of  sulphurous  acid,  and  one  of  borax  and 
bicarbonate  of  soda  (of  each  10  grains  to  the  ounce)  is  sometimes 
useful.  Neither  gargling  or  swabbing  out  the  fauces  are  of  much 
practical  value,  and  the  same  thing  is  true  of  the  local  application 
of  powdered  sulphur,  which  used  to  be  widely  practised. 

In  early  laryngeal  obstruction  a  steam  tent  is  indicated.  For 
its  relief  intubation  is  often  successful  in  the  hands  of  a  skilled 
operator.     Tracheotomy,  however,  is  preferable  in  most  cases. 

In  cardiac  failure  drugs  are  of  little  value,  but  the  hypodermic 
injection  of  liquor  strychninse  (2  to  5  m.)  every  four  hours,  and 
frequent  small  doses  of  alcohol  should  be  tried. 

A  do6e  of  from  2000  to  8000  units  of  antitoxin,  according  to  the 
severity  of  the  attack,  should  be  given  at  the  earliest  possible 
moment  in  every  case  when  the  patient  is  a  young  child.  In  the 
mild  form  of  attack  in  adults  it  may  be  withheld,  but  the  case 
must  then  be  carefully  watched.  No  regard  need  be  paid  to  the 
age  of  the  patient  in  regulating  the  dosage.  Should  there  be  even 
the  faintest  suggestion  of  croup,  a  full  dose  of  8000  units  should 
be  given  at  once,  as  the  necessity  for  tracheotomy  will  probably  be 
thereby  averted.  In  all  but  the  mildest  attacks  a  half  dose  should 
be  repeated  at  least  every  twenty-four  hours  until  the  exudation  has 
definitely  commenced  to  separate.  It  is  of  paramount  importance 
that  the  treatment  should  be  commenced  early.  The  serum  can  be  of 
no  use  after  the  tissues  have  been  irreparably  damaged  by  the  toxin 
already  absorbed.  The  injection  is  preferably  made  under  the  skin 
of  the  back  or  loins,  with  careful  previous  sterilisation  of  the  syringe 
and  its  needle.  Under  the  influence  of  early  treatment  with 
antitoxin,  the  development  of  the   disease  is  checked,  the  faucir.l 

VOL,  I  N 


178  MANUAL  OF  MEDICINE 

swelling  and  rhinorrhoea  abate,  and  the  membrane  separates 
earlier,  with  the  result  that  the  patient's  distress  is  greatly  lessened, 
laryngeal  obstruction  seldom  supervenes,  and  the  mortality  is  greatly 
reduced,  especially  amongst  the  tracheotomy  cases.  The  fact  that 
a  rash,  usually  of  a  measly,  or  urticarial  character,  or  a  short  period 
of  irregular  pyrexia,  or,  though  far  more  rarely,  some  pains  in  the 
joints  may  arise  a  week  or  ten  days  after  the  antitoxin  has  been 
given,  is  no  reason  against  its  employment,  as  they  are  never 
attended  with  any  permanent  ill  effect. 

F.  FooRD  Caiger. 


EPIDEMIC  PNEUMONIA 

The  clinical  features  of  croupous  pneumonia,  especially  its 
sudden  onset,  its  definite  course,  and  termination  in  a  crisis,  give  it 
a  striking  resemblance  to  such  specific  febrile  diseases  as  typhus 
fever  or  smallpox.  Nor  do  the  occasional  occurrence  of  true 
relapses  diminish  the  resemblance.  The  apparent  absence  of  in- 
fectiveness  in  the  vast  majority  of  instances  does  not  necessitate  its 
exclusion  from  the  list  of  specific  febrile  diseases,  as  such  maladies 
present  every  degree  of  infectivity,  the  amount  of  this  property 
being  determined  in  part  by  the  accessibility  of  the  infective  material 
to  the  surface  of  the  body  and  in  part  by  the  environmental  con- 
ditions. The  influence  of  environment  is  probably  at  its  minimum 
in  anthrax  and  smallpox.  It  is  very  great  in  rheumatic  fever  and 
in  pneumonia,  in  which  auxiliary  factors  are  required  besides  the 
"  unconditioned  microbe  "  to  complete  the  causation  of  the  disease. 
The  regular  seasonal  exacerbation  of  the  disease  (March  to  May), 
and  the  fact  that  in  certain  years  it  is  prevalent  in  such  excessive 
amount  as  to  deserve  the  name  of  "epidemic,"  confirm  the  same 
view.  The  official  figures  of  the  English  Registrar-General,  however, 
do  not  lend  themselves  to  a  demonstration  of  the  notion  that  in 
certain  years  croupous  pneumonia  is  epidemic ;  because  in  them  all 
forms  of  pneumonia  are  necessarily  reckoned  together.  Even  if 
an  attempt  were  made  to  separate  them,  without  universal  autopsies 
by  skilled  pathologists  the  results  would  require  to  be  accepted  with 
caution.  The  following  figures,  contributed  by  MM.  Montane  and 
Duponchel  to  the  French  Comite  de  Sante,  are  less  open  to  objec- 


EPIDEMIC   PNEUMONIA 


179 


tion.  They  give  the  morbidity  rate  from  pneumonia  in  the  50th 
Hne  regiment  of  Perigueux  among  an  adult  population  remaining  fairly 
constant  througliout  the  period.  The  corresponding  rates  for 
typhoid  fever  are  given  for  comparison  : — 


Pneumonia. 

Typhoid  Fever. 

Pneumonia. 

Tj'phoid  Fever. 

1878- 

83 

Der  100 

.00  per  100 

1885 

.50  per 

106 

1.36  per  180 

IS79 

36 

.28        „ 

1886 

113             M 

2-25       „ 

IS80 

57 

•42        ,, 

1887 

2.16             ,, 

1.85       ,> 

I88I 

00 

.00       ,, 

1888 

3-32       „ 

•52       „ 

IS82 

45 

•35      „ 

1889 

3-37       „ 

•52       „ 

IS83 

00 

4-32       „ 

1890 

■7?,      „ 

■36       „ 

1884 

40 

1.53  per  180 

1891 

1.85      „ 

.16       „ 

Thus  the  sickness  rate  from  pneumonia  was  irregular  until  1883, 
then  increased  regularly  until  1889,  when  the  epidemic  culmmated, 
subsequently  declining. 

It  may  be  argued  that  variations  like  the  above  may  be  caused 
merely  by  climatic  causes,  such  as  excessively  cold  winters.  The 
facts  do  not  confirm  this  view  ;  and  it  may  be  -added  that  the  favour- 
ing influence  of  climatic  influences  does  not  exclude  the  operation 
of  a  specific  micro-organism,  which,  although  it  cannot  "  uncon- 
ditioned "  cause  pneumonia,  is  so  far  the  essential  cause  that  the 
disease  does  not  arise  in  its  absence.  Bacteriology,  moreover,  shows 
the  presence  of  micro-organisms  in  pneumonia  (see  Vol.  IV.). 

It  may  be  that  there  is  more  than  one  disease  under  the  name 
croupous  pneumonia,  and  that  this  may  explain  the  difference  between 
sporadic  cases,  which  nearly  always  occur  singly,  and  epidemic  cases, 
occurring  in  small  groups  or  in  large  epidemics.  The  relationship 
between  sporadic  and  epidemic  pneumonia  may  resemble  that  between 
an  ordinary  febrile  catarrh  and  influenza,  or  between  summer  diarrhoea 
and  cholera,  or  between  catarrhal  jaundice  and  acute  yellow  atrophy 
of  the  liver.  It  may,  on  the  other  hand,  more  closely  resemble  that 
between  ordinary  ague  and  the  pandemic  ague,  which  has  devastated 
continents  in  the  past,  or  between  sporadic  and  epidemic  cerebro-spinal 
meningitis.  Cerebro-spinal  meningitis  becomes  epidemic  under  ex- 
tremely insanitary  local  conditions.  There  is  evidence  of  the  same 
kind  for  pneumonia.  This  is  well  instanced  by  an  outbreak  occur- 
ring in  1883  at  La  Salpetriere.  In  the  early  part  of  the  year  the 
sewers  of  this  establishment  were  in  process  of  reconstruction  and 
deep  trenches  dug,  the  work  being  executed  in  succession  in  three 
chief  courts  or  yards.  The  work  was  watched  by  a  number  of 
hysterical  and  epileptic  patients,  and  each  portion  of  the  work  as  it 
was  begun  was  followed  by  a  new  case  of  pneumonia.     Four  women 


i8o  MANUAL  OF  MEDICINE 

altogether  were  attacked,  those  who  had  not  been  outside  close  to 
the  trenches  escaping.  In  1874  Drs.  Grimshaw  and  Moore  noted 
an  increase  of  pneumonia  in  Dublin,  during  a  prolonged  drought, 
which  they  attributed  to  diminished  flushing  of  the  sewers.  A  serious 
epidemic  of  pneumonia  raged  in  Florence  in  the  winter  of  1877-78, 
which  was  ascribed  by  Bauti  to  foci  of  telluric  infection,  especially 
to  the  stagnation  of  the  River  Arno,  owing  to  the  prolonged  drought 
of  the  preceding  May  to  October. 

It  would  appear  also  that  foci  of  the  disease  may  exist  in  dwell- 
ings. Thus  Mendelsohn  ("  Die  Infect.  Nat.  der.  Pneum.,"  Ztschr.  f. 
klin.  Med.  1884,  t.  vii.  p.  191)  gives  the  instance  of  a  coachman  who 
went  to  lodge  on  the  3rd  of  April  1883  in  a  very  dirty  house,  the  first 
few  days  of  his  stay  there  being  occupied  in  cleansing  and  sweeping. 
On  the  20th  April  his  wife  fell  ill  with  pneumonia,  next  day  a  child 
of  five  years  old,  a  day  later  the  baby,  aged  fifteen  months ;  the 
third  child,  aged  three  years,  escaped.  On  the  26th  April  the  coach- 
man himself  began  with  the  same  disease.  He  was  removed  to  the 
hospital,  returning  to  the  same  lodging  convalescent  at  the  end  of 
May,  whence  he  had  to  return  to  hospital  in  June  with  a  second 
attack  of  pneumonia.  It  would  be  easy,  did  space  permit,  to  give 
numerous  instances  of  epidemic  pneumonia  in  connection  with 
prisons  and  barracks. 

The  evidence  of  direct  contagion  is  feeble.  It  would  appear  to 
be  exceptional ;  but  Netter  ("  Contagion  de  la  pneumonia,"  Arch, 
gen.  de  med.  1888,  7"  serie,  t.  xxi.  p.  530)  has  collected  a  number  of 
scattered  observations.  The  following  case,  reported  by  Schroeter, 
may  be  instanced.  A  man  aged  twenty-four  years  had  an  attack  of 
rheumatism  in  October  1887.  After  six  weeks,  when  he  was 
convalescent,  his  father  was  brought  to  the  house  with  left- sided 
pneumonia,  and  occupied  the  same  bed  as  the  son.  On  the  eighth 
day  of  the  pneumonic  attack,  the  son,  who  had  not  hitherto  left  his 
room,  began  with  typical  right-sided  pneumonia.  Wynter  Blyth  has 
narrated  the  case  of  a  young  woman  who  contracted  pneumonia 
while  nursing  her  father  for  this  disease,  and  who,  after  she  had  been 
taken  to  her  own  home,  communicated  the  same  disease  to  her 
husband.  The  following  case  is  interesting,  as  the  infection  appears 
to  have  clung  to  fomites  {Lyon  ?ned.,  28th  Avril  1889).  -^  butcher's 
child  was  convalescing  from  pneumonia,  and  about  this  time  the 
butcher's  servant  boy  began  with  pneumonia  (loth  December).  He 
was  removed  to  the  hospital,  and  on  the  15th  December  a  second 
boy  took  his  place,  sleeping  on  the  same  bed  and  in  the  same 
clothes.     Two  days  later  he  was  seized  with  pneumonia.     A  third 


EPIDEMIC   PNEUMONIA  i8i 

boy  arrived  on  the  i8th  December;  he  slept  \Yith  the  second  boy 
for  two  nights,  and  thirty  hours  later  began  with  pneumonia. 

The  preceding  observations  raise  a  strong  presumptive  case  for 
the  contagiousness  of  pneumonia,  under  exceptionally  insanitary 
conditions  of  soil  or  dwelling.  It  is  not  likely  that  the  multiple 
cases  are  explicable  merely  as  coincidences. 

Outbreaks  of  pneumonia  have  occurred  in  this  country  at 
Middlesborough  (682  cases  and  143  deaths)  and  at  Scotter.  In  the 
former  outbreak  Klein  was  unable  to  discover  either  the  micro- 
coccus of  Friedlander  or  the  diplococcus  of  Frankel  and  Weich- 
selbaum,  but  found  instead  a  distinctive  bacillus.  This  observation, 
among  others,  renders  it  likely  that  in  croupous  pneumonia  we 
have  to  deal  with  several  diseases,  not  yet  differentiated.  This  fact, 
if  confirmed,  may  explain  the  varying  infectivity  of  the  disease.  One 
circumstance  has  to  be  borne  in  mind  in  connection  with  epidemics 
of  pneumonia.  Some  of  them  have  coincided  in  time  with  the 
prevalence  of  epidemic  influenza.  It  may  be,  therefore,  that  the 
pneumonia  was  but  a  local  complication  of  this  disease.  This 
explanation  only,  however,  accounts  for  a  small  proportion  of  the 
recorded  epidemics  of  pneumonia. 

Historically  there  are  numerous  accounts  of  epidemic  pneumonia. 
Some  of  these  have  spread  over  wide  tracts  of  country,  as  for 
instance  those  of  1564  in  Italy,  Switzerland,  and  Western  Germany, 
of  1779  in  Italy,  of  1783-85  in  France,  of  1863-75  in  the  United 
States,  and  of  1857  in  Bolivia,  Peru,  and  Western  Brazil  (Hirsch). 
We  still  lack,  however,  accounts  of  true  epidemics  of  pneumonia 
in  which  careful  autopsies  have  been  made  of  fatal  cases,  and  in 
which  the  exact  cause  of  the  infection  has  been  traced  and 
described. 

The  clinical  characters  of  the  disease  will  be  treated  of  else- 
where. 

Arthur  Newsholme. 


MANUAL  OF   MEDICINE 


INFECTIVE    MENINGITIS 

The  pia-arachnoid  membranes  are  not  infrequently  the  seat  of 
inflammation  consequent  upon  the  invasion  of  several  distinct 
micro-organisms.  Associated  with  the  different  varieties  of  causal 
virus  there  is  some  difference  in  the  clinical  course  and  symptoms 
of  the  resulting  affections.  The  various  forms  at  present  recognised 
are  as  follows  : — 

I.  Epidemic  cerebro- spinal  meningitis.  2.  Posterior  basic 
meningitis.     3.   Suppurative  meningitis.     4.   Tuberculoas  meningitis. 

In  the  first  and  second  forms,  and  also  in  the  third,  when  the 
disease  is  not  secondary  to  pneumonia,  erysipelas,  middle  ear 
disease  or  injury,  as  it  usually  is,  the  anatomical  lesions  found  post- 
mortem are  almost  entirely  confined  to  the  meninges,  and  the 
symptoms  presented  by  the  patient  are  as  entirely  referable  to  the 
meningeal  inflammation.  For  these  reasons  these  maladies  will  be 
described  here ;  the  tuberculous  variety,  as  well  as  the  meningitis 
associated  with  syphilis  and  new  growths,  will  be  treated  of  else- 
where. 

Epidemic  Cerebro-spinal  Meningitis 
Syn.  Cerebro-spinal  Fever — Spotted  Fever — Cerebral  Typhus 

An  acute  febrile  disorder  characterised  by  symptoms  indicative 
of  special  affection  of  the  central  nervous  system,  and  very  frequently 
accompanied  by  a  rash. 

Since  1805  numerous  epidemics  on  the  Continent  of  Europe,  in 
Ireland,  and  in  North  America  have  been  recorded.  Great  Britain 
has  been  free  from  large  outbreaks,  though  minor  ones  have  not 
been  rare,  and  sporadic  cases  not  at  all  infrequent.  The  malady 
is  most  prevalent  in  temperate  latitudes,  but  it  also  occurs  in  sub- 
tropical climates.  On  a  priori  grounds  it  might  be  expected  to 
have  a  universal  distribution,  a  view  which  receives  confirmation 
from  its  occurrence  in  India,  and  from  the  record  of  a  few  cases 
in  Australasia  and  the  Fiji  islands. 

The  epidemics  have  occurred  mostly  in  winter  and  spring,  and 
among  the  predisposing  causes  may  be  enumerated  ill  or  insufficient 
nourishment,    exhaustion,    overcrowding,    and    unwholesome    sur- 


INFECTIVE  MENINGITIS  183 

roundings.  Notwithstanding  the  frequently  recorded  epidemics 
among  persons  closely  associated,  such  as  are  found  in  gaols,  schools, 
workhouses,  asylums,  and  barracks,  direct  contagion  is  slight  or 
negative,  and  the  exact  method  of  communication  is  at  present 
undetermined.  It  is  probably  due  to  this  circumstance  that  com- 
paratively few  individuals  are  attacked  in  any  epidemic. 

While  children  and  young  adults  are  especially  liable,  no  age 
is  exempt,  and  though  robust  males  in  the  prime  of  life  are 
frequently  attacked,  yet  after  thirty-five  years  of  age  the  liability  is 
slight.  The  disease  has  been  known  to  be  transmitted  from  the 
mother  to  the  foetus  iti  iitero,  as  shown  by  identical  post-mortem 
appearances  in  both. 

After  an  incubation  period  of  unknown  though  probably 
short  duration,  during  which  there  may  be  vague  or  ill-pronounced 
premonitory  symptoms,  the  disease  declares  itself  with  remarkable 
suddenness,  the  principal  initial  symptoms  being  intense  occipital 
headache,  shivering,  and  vomiting.  I'hese  symptoms,  accompanied 
by  prostration,  rapidly  increase  in  intensity ;  the  patient  tosses  rest- 
lessly about,  frequently  becoming  delirious ;  the  face  is  drawn  and 
pale ;  an  herpetic  eruption  appears  on  the  face,  and  purpuric  spots 
on  the  legs  and  elsewhere.  The  skin  is  extremely  sensitive.  The 
head  is  often  retracted,  and  there  is  pain  and  tenderness  in  the 
back  and  limbs,  frequently  severe.  The  pupils  are  small,  the  con- 
junctivae injected,  and  frequently  there  is  strabismus  and  sometimes 
ptosis  and  facial  spasms.  The  condition  of  the  tongue  is  variable, 
though  in  severe  cases  it  is  much  furred.  The  abdomen  is  retracted 
and  the  bowels  constipated.  By  the  third  or  fourth  day  the  pulse 
and  respiration  increase  in  frequency,  the  temperature  ranging  from 
100°  to  104°.  The  decubitus  is  lateral,  with  the  legs  drawn  up. 
The  vomiting  continues.  The  prostration  and  the  spasm  of  the 
muscles  of  the  neck  and  back  increase  in  severity.  There  is  retention 
or  incontinence  of  urine,  and  the  patient,  who  has  been  gradually 
becoming  deaf  and  drowsy  with  sighing  respiration,  lapses  into 
unconsciousness,  and  dies  from  pulmonary  congestion  and  oedema. 

Though  the  foregoing  may  be  taken  as  the  description  of  a 
severe  case,  it  is  necessary  to  point  out  that  the  disease  presents 
more  than  one  clinical  picture.  Four  or  five  types  are  usually 
described — malignant,  severe,  mild,  and  abortive,  and  considerable 
variety  of  symptoms  characterises  different  epidemics. 

In  the  malignant  form  the  patient  may  die  in  a  comparatively  few 
hours  in  a  condition  of  collapse  and  coma.  It  is  in  these  cases  that 
petechiae  and  purpuric  blotches  are  so  well  marked  and  of  such  fatal 


1 84  MANUAL  OF  MEDICINE 

significance.  In  the  milder  forms  all  the  symptoms  are  less  violent, 
and  some,  such  as  the  petechicC,  are  absent.  The  abortive  type  is 
usually  recognised  by  the  presence  of  headache,  and  some  malaise 
occurring  during  an  epidemic.  To  these  may  be  added  the  iiiter- 
7nittetit  variety,  in  which  remissions  and  exacerbations  of  the  symp- 
toms occur,  and  the  typhoid,  wherein  muttering  delirium,  dry, 
brown-furred  tongue,  and  other  typhoid  symptoms  are  prominent 
phenomena. 

Several  symptoms  and  eomplieations,  some  of  which  have  im- 
portant sequelae,  require  to  be  specially  noticed.  Herpes  of  the  face 
and  lips  is  present  in  the  majority  of  cases,  and  may  occur  also  on 
other  parts  of  the  body.  Though  herpes  is  the  most  common,  urti- 
caria, pemphigoid  bullae,  and  erythematous  roseolar  eruptions  are 
also  described.  In  the  severe  and  malignant  types  the  skin  is  the 
seat  of  hsemorrhagic  petechiae  and  blotches,  and  these  may  be  so 
extensive  and  prominent  as  to  warrant  the  term  cutaneous  hjemor- 
rhages.  Of  late  years,  however,  less  note  has  been  taken  of  rashes 
or  eruptions,  with  the  exception  of  herpes.  Coryza  is  occasionally 
present,  manifesting  itself  either  before  the  outbreak  or  during  the 
attack.  The  chief  interest  of  this  symptom  is  that  the  nasal  and 
faucial  mucosae  may  possibly  be  the  portals  of  entry  of  the  virus. 

Of  late  attention  has  been  drawn  to  Kernig's  sign,  by  which  is 
meant  the  reflex  contraction  of  the  flexor  muscles  which  occurs 
when  an  attempt  is  made  to  extend  the  leg  on  the  thigh,  as  in- 
dicative of  meningitis.  To  elicit  this  phenomenon  the  patient  must 
be  placed  in  the  sitting  posture.  The  condition  of  the  reflexes  is 
variable,  that  is,  they  may  be  normal,  exaggerated,  or  absent. 

The  temperature  mostly  ranges  between  ioo°  and  104°,  though 
in  some  cases,  usually  rapidly  fatal,  it  may  rise  but  little  or  not  at 
all ;  while  on  the  other  hand  it  may  ascend  as  high  as  107°.  There 
is  no  special  curve  or  type,  and  all  that  can  be  said  is  that  it  is 
irregularly  remittent. 

The  pulse  is  sometimes  rapid,  100-120°,  at  any  rate  in  children, 
for  in  adults  it  may  be  quite  slow,  and  quite  out  of  relation  to 
the  temperature.  There  is  little  to  be  said  about  the  respiration, 
except  that  it  may  be  laboured  and  sighing ;  still,  pulmonary  com- 
plications must  always  be  remembered. 

One  of  the  most  frequent  issues  is  eye  trouble,  such  as  palsy  of 
the  ocular  muscles,  and  conjunctivitis,  which  may  become  ulcerative. 
Blindness  has  not  infrequently  resulted  from  suppuration  of  the 
internal  parts  of  the  eye.  Disease  of  the  ear,  resulting  in  per- 
rnanent  deafness  or  deaf- mutism  in  young  children,  is  not  at  all 


INFECTIVE   MENINGITIS  185 

uncommon,  and  is  decidedly  more  frequent  than  in  posterior  basic 
meningitis.  This  sequela  is  due  to  direct  extension  of  the  inflam- 
mation from  the  meninges  to  the  labyrinth,  and  also  to  the  affection 
of  the  tympanum.  Besides  the  eye  and  ear,  the  special  senses  of 
taste  and  smell  may  also  become  impaired. 

Other  less  constant  and  less  common  features  are  the  presence 
of  albumen  in  the  urine,  heematuria,  optic  neuritis,  and,  in  children, 
convulsions. 

Perhaps  the  most  important  sequela  is  chronic  hydrocephalus. 
This  usually  manifests  itself  during  convalescence ;  but  its  presence 
may  be  suspected  if  the  vomiting  be  protracted,  and  especially  if 
there  be  unaccountable  rises  of  temperature  and  the  headache  be 
persistent. 

Other  complications  and  sequelae  which  may  be  met  with  are, 
suppurative  and  non- suppurative  arthritis  and  periarthritis,  pneu- 
monia, broncho-pneumonia,  pleurisy,  peri-  and  endo-carditis,  and 
palsy  of  the  limbs.  The  paralysis  of  the  extremities  may  be 
hemiplegic,  paraplegic,  or  monoplegic  in  distribution.  If  mono- 
plegic,  the  arm  is  the  part  most  frequently  affected. 

Emaciation  is  a  distinct  feature  of  the  disease  ;  sometimes  it  is 
extremely  marked  and  then  is  often  associated  with  severe  damage 
to  the  central  nervous  system. 

The  principal  and  indeed  the  only  essential  morbid  appear- 
ance is  a  suppurative  or  fibrino-purulent  leptomeningitis  of  the 
brain  and  cord.  The  distribution  of  the  exudation  in  the  brain  is 
irregular,  and  affects  both  vertex  and  base.  In  amount  and  extent 
it  is  extremely  variable  ;  it  may  be  considerable  even  in  rapidly 
fatal  cases,  though  under  these  latter  circumstances  mere  hyperEemia 
only  may  be  visible  to  the  naked  eye.  In  the  spinal  cord  the 
exudation  is  most  marked  on  the  posterior  aspect  and  towards  the 
lower  end.  The  cerebral  ventricles  are  usually  distended  with 
turbid  fluid,  and  the  lining  membrane  disintegrated.  Though  the 
spleen 'may  be  much  enlarged  it  is  frequently  but  little  or  not  at 
all  increased  in  size.  Micro-sections  show  that  the  subarachnoid 
exudation  is  principally  cellular,  and  chiefly  leucocytic,  and  the 
presence  of  micro  -  organisms  in  the  exudate  has  been  demon- 
strated. 

In  addition  to  the  essential  features  there  are  often,  as  already 
intimated,  pneumonia,  broncho-pneumonia,  pleurisy,  peri-,  and  endo- 
carditis. 

Special  methods  of  investigation  (e.^^.  NissFs  and  Marchi's)  have 
deterrnined  the  existence  of  degenerative  changes  in  the  nerve  cell§ 


1 86  MANUAL  OF  MEDICINE 

and  fibres  of  the  central  nervous  system.  The  cells  may  be  swollen, 
granular,  their  shape  disfigured  and  their  chromatic  bodies  absent 
(chromatolysis).      The  nucleus  may  be  displaced  or  even  lost. 

Bacteriology. — The  microbe  to  which  the  disease  is  due  is 
the  diplococcus  iiitracellularis  meningitidis  (\\"eichselbaum).  This 
organism  has  been  discovered  not  only  in  the  exudation,  examined 
post-mortem,  but  has  also  been  obtained  from  the  spinal  fluid  with- 
drawn by  lumbar  puncture  during  life. 

The  diplococcus  is  very  small,  and  occurs  most  often  in  groups 
inside  the  cells  of  the  exudation.  Here  and  in  cultures  it  is  fre- 
quently grouped  in  pairs,  and  for  this  reason  has  been  described  by 
some  observers  as  a  tetracoccus.  It  stains  with  the  ordinary  aniline 
dyes,  but  does  not  stain  by  Gram's  method.  One  of  its  character- 
istics, as  described  by  Weichselbaum,  is  its  very  brief  vitality,  a 
point  in  which  it  differs  from  the  diplococcus  of  posterior  basic 
meningitis.  There  are  other  slight  differences  both  on  culture  and 
on  inoculation  between  these  two  micro-organisms,  but  it  is  probable 
that  they  are  closely  related. 

From  the  pneumococcus  the  diplococcus  intracellularis  differs 
in  many  respects,  morphologically,  in  culture  and  on  inoculation. 
The  diplococcus  intracellularis  is  found  not  only  in  the  epidemic, 
but  also  in  the  sporadic  cases  of  this  disease.  Some  cases,  how- 
ever, which  would  in  the  past  have  been  included  under  this  head, 
are  now  known  to  be  due,  some  to  the  diplococcus  of  posterior 
basic  meningitis,  some  to  the  pneumococcus,  which  until  recently 
was  regarded  as  responsible  for  the  malady  now  under  considera- 
tion. 

AVhether  the  pneumococcus  does  give  rise  to  an  epidemic  form 
of  meningitis  is  uncertain  ;  but  there  are  certain  relationships 
apparently  existing  between  pneumonia  and  the  epidemic  cerebro- 
spinal form  of  meningeal  inflammation  which  are  striking,  such  are 
the  same  seasonal  prevalence  and  frequent  coexistence  of  the  two 
diseases,  especially  in  crowded  gaols  and  barracks,  the  sudden  onset 
and  marked  liability  to  the  appearance  of  herpes. 

Prognosis. — The  mortality  in  this  disease,  especially  in  some 
epidemics,  is  high,  and  has  ranged  from  20  to  80  per  cent,  so 
that  the  average  mortality  may  be  assumed  to  be  about  50  per 
cent.  In  the  more  malignant  cases  death  may  take  place  in  a 
few  hours  to  a  few  days  (1-8).  As  a  rule,  convalescence  is  tardy. 
Mild  cases  may  get  well  in  a  week  or  two,  while  others,  where  the 
symptoms  have  been  only  moderately  severe,  may  last  for  five  or 
six  weeks  or  longer.      It  is  advisable  to  wait  for  ten  to  fourteen  days 


INFECTIVE   MENINGITIS  187 

after  the  symptoms  have  subsided  before  stating  that  the  patient  is 
to  be  regarded  as  safe. 

Apart  from  special  complications,  such  as  hj'drocephalus,  otitis, 
endocarditis,  and  pneumonia,  there  is  always  grave  danger  from 
asthenia  and  marasmus,  conditions  which  may  follow  mild  as  well 
as  severe  cases.  When  these  conditions  are  marked  the  patient, 
after  lingering  for  months,  usually  dies  from  toxsemic  cachexia. 
The  prognosis  must  depend  chiefly  on  the  severity  of  the  symptoms, 
though  some  assistance  may  be  derived  from  the  character  of  the 
epidemic  and  the  time  it  has  lasted,  for  the  cases  are  usually  more 
seveie  at  the  beginning  than  at  the  end  of  the  outbreak.  When 
the  initial  symptoms  are  severe,  when  coma  supervenes,  when 
haemorrhagic  blotches,  especially  if  extensive,  make  their  appear- 
ance, the  prognosis  is  extremely  grave. 

The  diagnosis  will  depend  in  the  first  place  on  the  recognition 
of  the  more  striking  and  salient  symptoms,  namely,  headache, 
vomiting,  fever,  pain  in  the  back,  retraction  of  the  head  and  the 
presence  of  herpes.  Few  disorders  have  such  a  sudden  onset,  and 
are  accompanied  from  the  first  by  so  much  prostration.  A  positive 
and  early  diagnosis  might  therefore  seem  a  simple  matter.  Yet, 
owing  to  the  presence  of  headache,  of  constipation,  and  of  the 
absence  of  spots,  enteric  fever  has  been  mistaken  for  cerebro-spinal 
meningitis.  With  typhus  fever  it  might  more  easily  be  confounded 
owing  to  the  presence  of  a  petechial  rash  and  of  prostration.  The  rash, 
however,  appears  more  suddenly  than  that  of  typhus,  from  which  it  is 
further  distinguished  by  the  greater  intensity  of  the  nervous  symptoms. 
Purpura  hemorrhagica  and  hsemorrhagic  variola  have  both  been  con- 
fused with  this  disease.  From  tuberculous  meningitis  it  is  distinguished 
by  the  gradual  onset,  the  less  severe  symptoms  and  the  absence  of 
rash  in  the  latter ;  from  suppurative  meningitis,  by  the  absence  of 
some  obvious  exciting  cause,  such  as  traumatism  or  disease  of  the 
ear ;  from  influenza,  when  severe,  and  when  there  is  fever,  headache, 
pain  in  the  back  and  prostration,  by  the  absence  of  vomiting,  of  any 
marked  affection  of  the  cranial  nerves  and  retraction  of  the  head. 

Heart  or  lung  complications,  especially  if  early,  might  cause  a 
difficulty  in  coming  to  a  conclusion,  for  the  occurrence  of  cerebro- 
spinal symptoms  might  lead  to  the  suspicion  that  the  affection  of 
the  central  nervous  system  was  secondary  and  metastatic. 

As  may  have  been  inferred  from  a  consideration  of  the  morbid 
appearances,  the  line  of  treatment  must  be  symptomatic  and 
palliative,  and  in  a  great  measure  expectant.  Still  there  is  a  con- 
sensus  of   opinion   in    favour    of   giving  opium,   or  what  seems  to 


1 88  MANUAL  OF  MEDICINE 

answer  better,  morphia,  by  hypodermic  injection,  in  order  to  allay 
the  general  irritability,  to  soothe  the  pain,  to  promote  sleep,  and  in 
some  degree  to  restrain  vomiting. 

The  abstraction  of  cerebro-spinal  fluid  by  lumbar  puncture  has 
been  practised  not  unfrequently  of  later  years,  and  cases  of  cerebro- 
spinal meningitis  are  reported  wherein  this  procedure  has  been 
followed  by  recovery.  Though,  owing  to  the  general  character 
of  the  disease  and  the  parts  principally  affected,  too  much  must  not 
be  expected  from  the  removal  of  cerebro-spinal  fluid,  the  results 
from  lessening  the  tension  are  sufficiently  encouraging  to  warrant  its 
adoption  in  this  form  of  meningitis. 

Subcutaneous  injections  of  Liq.  hydrarg.  perchlor.  have  been 
strongly  advocated,  improvements  following,  it  is  said,  the  second 
or  third  injection. 

The  headache  and  spinal  pain  are  sometimes  alleviated  by  the 
use  of  ice-bags,  while  blisters  have  been  found  unsatisfactory,  and 
their  use  is  to  be  deprecated. 

The  results  from  general  abstraction  of  blood  are  not  en- 
couraging, though  local  depletion  by  means  of  leeches  may  possibly 
be  found  to  afford  some  relief. 

To  check  the  vomiting,  hydrocyanic  acid  with  bicarbonate  of 
soda  in  simple  draught  or  in  effervescing  mixture  may  be  tried, 
alone  or  in  combination  with  one  of  the  bromides  as  a  sedative. 
Though  the  foregoing  and  other  drugs  are  sufficiently  approved  for 
restraining  retching  and  vomiting,  their  exhibition  will  depend  on 
the  tolerance  of  the  stomach  to  interference,  and  it  may  be  found 
advisable  to  adopt  a  cold  liquid  and  scanty  dietary  until  the  main 
symptoms  are  subsiding. 

Constipation  should  be  treated  by  enemata  until  convalescence 
has  set  in  and  the  alimentary  canal  is  in  a  condition  to  bear 
aperients. 

During  convalescence,  which  is  frequently  protracted  and  accom- 
panied by  general  debility  and  emaciation,  headache  is  not  un- 
common, and  sometimes  severe ;  for  this  antipyrin  or  chloral  and 
bromides  are  indicated  ;  while  as  a  general  tonic  a  mixture  of  quinme 
and  iodides  should  be  administered. 

R.  G.  Hebb. 


INFECTIVE  MENINGITIS  189 


Posterior  Basic  Meningitis 


The  recognition  of  posterior  basic  meningitis  as  a  specific  disease 
is  of  quite  recent  date.  It  had  been  observed  for  many  years  that 
there  occurred,  chiefly  in  infants,  a  disease  characterised  by 
prolonged  and  extreme  retraction  of  the  head,  and  it  was  with 
reference  to  this  striking  symptom  that  the  description  of  the 
disease  by  Dr.  Gee  and  Dr.  Barlow  in  a  paper  on  "  The  Cervical 
Opisthotonos  of  Infants  "  appeared  in  18 78.  It  was  not,  however, 
until  Dr.  Carr  in  1897,  and  shortly  afterwards  Dr.  Barlow  and  Dr. 
Lees,  drew  attention  to  the  constancy  of  the  symptoms,  and  the 
general  likeness  to  a  specific  disease,  that  its  true  position  was 
recognised,  and  its  infective  nature  was  finally  confirmed  by  the 
discovery  of  the  micro-organism  to  which  it  is  due. 

The  exact  relationship  of  this  disease  to  that  known  as 
"Epidemic  Cerebro- spinal  ^Meningitis "  has  not  yet  been  fully 
ascertained,  for  although  the  bacteriological  evdence  shows  them 
to  be  very  closely  related,  if  not  identical,  there  are  slight  differences 
in  the  bacteriology,  and  more  particularly  in  the  clinical  aspect  of 
the  two  conditions,  which  make  it  perhaps  desirable,  at  any  rate  for 
the  present,  to  consider  them  separately. 

Etiology. — Posterior  basic  meningitis,  though  it  sometimes 
occurs  in  later  childhood,  is  most  common  during  the  first  year  of 
life,  and  seldom  occurs  after  the  end  of  the  second  year.  It  is 
frequently  seen  during  the  first  six  months  of  life,  a  period  at  which 
tuberculous  and  epidemic  cerebro -spinal  meningitis  are  quite 
uncommon.  Girls  and  boys  are  affected  with  about  equal  frequency. 
The  disease  shows  a  very  marked  seasonal  variation  ;  it  is  much 
commoner  in  winter  and  spring  than  in  summer  :  fully  two-thirds  of 
the  cases  have  their  onset  between  the  beginning  of  January  and 
the  end  of  May. 

It  would  appear  to  be  endemic  in  most  large  towns  and  cities, 
and  cases  have  been  observed  both  on  the  Continent  and  in  America, 
so  that  although  it  is  impossible  yet  to  say  anything  definite  as  to 
its  geographical  distribution,  there  can  be  little  doubt  that  it  is  a 
widely-spread  disease,  and  is  by  no  means  limited  to  the  British  Isles. 

In  spite  of  the  infective  character  of  the  disease  no  evidence 
whatever  of  transmission  from  infant  to  infant  has  yet  been  observed. 
The  close  resemblance  to  the  sporadic  cases  of  so-called  epidemic 
cerebro-spinal  meningitis  must,  however,  be  borne  in  mind,  for  it 
is  at  least  possible  that  the  posterior  basic  disease  of  infants  is  only 
one  sporadic  manifestation  of  the  epidemic  disease. 


I90  MANUAL  OF   MEDICINE 

In  some  cases  a  history  of  a  fall  or  blow  preceding  the  onset  of 
the  illness  is  obtained  ;  in  others  some  slight  catarrhal  symptoms,  a 
cough  or  "a  cold"  have  occurred,  but  it  seems  very  doubtful 
whether  these  bear  any  causal  relation  to  the  disease. 

Bacteriology. — The  immediate  cause  of  the  meningitis  is  an 
infection  of  the  brain  with  a  specific  micro-organism,  the  diplococcus 
of  posterior  basic  meningitis,  which  shows  only  very  slight  differences 
from  the  diplococcus  intracellularis  of  epidemic  cerebro- spinal 
meningitis.  It  must  not  be  confused  with  the  pneumococcus,  from 
which  it  differs  widely,  and  from  which  it  can  easily  be  distinguished 
by  culture  and  by  inoculation.  The  diplococcus  is  very  small ;  its 
average  length,  measured  in  the  meningeal  exudation,  is  1.2  /x  to 
1.5  [jb.  The  two  cocci  of  which  it  consists  have  their  opposed 
surfaces  more  or  less  flattened,  and  are  separated  by  a  narrow  clear 
space.  It  shows  a  marked  tendency,  especially  in  cultures,  to 
grouping  in  pairs  side  by  side,  so  that  an  appearance  like  that  of  a 
tetracoccus  is  produced.  It  is  aerobic,  and  is  easily  cultivated  at 
a  temperature  of  about  37°  C.  Its  vitality  is  greater  than  that  of 
the  pneumococcus  or  of  the  diplococcus  intracellularis,  while  its 
virulence  on  inoculation  seems  to  be  less. 

The  diplococci  are  found  both  free  and  in  the  cells  of  the 
exudation,  and  in  the  cerebro-spinal  fluid,  during  the  acute  stage  of 
the  disease,  but  they  disappear  usually  after  a  few  weeks  as  the 
inflammation  subsides. 

It  is  probable  that,  as  in  other  forms  of  meningitis,  a  mixed 
infection  may  occasionally  occur,  other  micro-organisms  gaining 
access  to  the  meninges  either  at  the  same  time  with  the  specific 
micro-organism  or  at  a  later  period ;  but  such  an  occurrence  would 
seem  to  be  extremely  rare. 

The  channel  of  infection  in  this  disease  has  not  yet  been 
ascertained.  There  is  no  evidence  to  show  that  infection  occurs 
through  the  ear. 

Symptoms. — The  onset  of  the  disease  is  sudden  :  an  ap- 
parently healthy  infant  is  seized  with  vomiting,  becomes  feverish, 
and  perhaps  screams  without  apparent  cause.  Convulsions  may 
occur  at  this  stage,  but  more  commonly  begin  later. 

Within  a  few  hours,  or  at  most  within  a  few  days,  of  the  onset 
the  head  is  noticed  to  be  drawn  back ;  sometimes  indeed  this  is  the 
first  symptom  noticed.  Of  all  the  symptoms  of  posterior  basic 
meningitis  the  head  retraction  is  by  far  the  most  constant  and  the 
most  characteristic.  It  appears  very  early  in  the  disease,  and  lasts 
usually  for  several  weeks  or  even  months.     The  retraction  varies  in 


INFECTIVE   MENINGITIS  191 

degree  in  different  cases,  and  may  vnry  from  day  to  day ;  it  may  be 
so  slight  as  to  be  only  just  noticeable,  but  in  the  majority  of  cases 
is  quite  obvious,  and  in  some  is  so  extreme  that  the  occiput  almost 
touches  the  buttocks.  Where  this  happens  there  is  extreme 
opisthotonos  of  the  dorsal  spine  as  well  as  of  the  cervical ;  more 
often,  however,  the  opisthotonos  is  limited  to  the  cervical  region,  the 
head  being  thrown  backwards,  so  that  there  is  barely  room  for  two 
fingers  between  the  occiput  and  the  upper  dorsal  spine,  while  the 
dorsal  spine  itself  is  rather  in  a  position  of  kyphosis. 

Clonic  convulsions  may  occur  at  any  period  of  the  disease,  but 
they  are  not  a  marked  feature,  and  are  sometimes  absent  throughout. 
A  commoner  condition  is  one  of  tonic  rigidity,  and  as  the  disease 
becomes  advanced  the  infant  often  lies  on  its  side  with  head  thrown 
back  and  limbs  rigidly  extended,  the  forearms  at  the  same  time 
being  fully  pronated,  so  that  the  palms  of  the  clenched  hands  look 
outwards,  while  the  shoulders  are  drawn  back,  and  the  legs  tend  to 
cross  owing  to  some  adductor  spasm  of  the  thighs. 

Champing  movements  of  the  jaw  and  grinding  of  the  teeth  are 
curiously  common  in  this  disease,  although  not  peculiar  to  it ;  either 
of  them  may  continue  sometimes  for  hours. 

With  the  head  retraction  there  is  often  a  staring  appearance  of 
the  eyes,  due  apparently  to  a  spasmodic  raising  of  the  upper  lid,  so 
that  the  palpebral  fissure  is  widely  open  ;  and  this  staring  appearance 
becomes  even  more  noticeable  when  there  is  added  to  it  the  vacant 
look  of  blindness. 

Blindness  is  present  in  about  one-third  of  the  cases  of  posterior 
basic  meningitis,  and  appears  to  be  quite  independent  of  any  gross 
changes  in  the  eye :  there  can  be  little  doubt  that  it  is  entirely 
central  in  origin.  In  most  cases,  even  with  complete  blindness, 
there  is  no  optic  neuritis,  and  in  the  rare  cases  where  inflammatory 
changes  are  present  in  the  disc  they  are  usually  very  slight. 
Paralysis  of  the  ocular  muscles  is  seldom  a  marked  symptom ;  in 
nearly  half  the  cases  strabismus  is  absent  altogether,  and  when 
present  it  is  often  slight  and  transitory  ;  paralysis  of  other  cranial 
nerves  is  extremely  rare.  Slight  nystagmus  is  not  uncommon. 
Deafness  has  occurred  in  a  few  cases,  but  is  quite  exceptional. 

Sensation  appears  to  be  normal ;  there  is  evident  pain  wben  any 
attempt  is  made  to  push  the  head  forward  into  its  natural  position, 
but  otherwise  the  infant  lies  quietly  on  its  side,  apparently  free  from 
pain,  and  only  giving  a  sudden  start  when  disturbed. 

The  superficial  reflexes  are  unaltered ;  the  tendon  jerks, 
especially  the  knee  jerks,  are  usually  over-active,   especially  in  the 


192  MANUAL  OF  MEDICINE 

chronic  stage  of  the  disease,  when  there  is  sometimes  ankle-clonus. 
The  "  tache  cerebrale  "  is  a  less  marked  feature  in  this  disease  than 
in  tuberculous  meningitis. 

Vomiting  is  one  of  the  most  constant  of  the  early  symptoms,  and 
is  usually  more  or  less  persistent  throughout  the  disease.  The 
bowels  show  less  tendency  to  costiveness  than  in  tuberculous 
meningitis,  and  diarrhoea  is  a  common  complication,  especially 
towards  the  end  of  the  illness.      The  urine  shows  nothing  abnormal. 

The  pulse  is  usually  more  rapid  than  normal  throughout,  and 
if  irregularity  occurs  it  is  slight  and  transitory  ;  the  marked  slowness 
and  irregularity  of  the  pulse  which  occurs  in  tuberculous  meningitis 
is  not  observed  at  any  period  of  the  posterior  basic  disease. 

The  respiration,  especially  in  the  later  stage,  frequently  shows 
some  periodic  irregularity,  long  pauses  alternating  with  a  series  of 
rather  rapid  respirations,  but  without  the  rhythmic  increase  and 
decrease  in  depth  which  characterises  the  Cheyne-Stokes'  type  of 
breathing. 

The  temperature  at  the  onset  is  raised  to  102°  or  103°,  and 
there  is  irregular  pyrexia  usually  for  the  first  two  or  three  weeks. 
The  temperature  then  gradually  falls,  and  may  remain  normal  for 
the  rest  of  the  illness,  or  may  become  subnormal  where  there  is 
much  vomiting  and  exhaustion.  Sudden  hyperpyrexia  may  occur 
just  before  death.  In  some  cases,  and  these  usually  the  more 
severe,  there  is  persistent  and  considerable  pyrexia  of  a  remittent  or 
intermittent  type  throughout  the  illness. 

In  most  cases  where  the  disease  is  prolonged  beyond  a  few 
weeks-  wasting  is  a  marked  feature ;  the  emaciation  may  be 
extreme. 

Rashes,  especially  the  herpes  and  purpura,  which  are  so  common 
in  the  epidemic  form  of  meningitis,  are  almost  invariably  absent  in 
the  posterior  basic  disease  of  infants,  but  too  much  stress  must  not 
be  laid  on  this  as  a  distinguishing  feature,  for  very  rarely  a  labial 
herpes  has  occurred  at  the  onset,  and  at  a  later  period  a  generalised 
blotchy  erythema  has  been  seen. 

Complications. —  The  most  important,  because  the  most 
frequent,  and  the  most  fatal  is  hydrocephalus.  In  most  cases  where 
the  disease  lasts  longer  than  a  few  weeks  the  head  is  noticed  to  be 
increasing  in  size,  the  fontanelle  becomes  bulged,  and  the  eyes  are 
turned  downwards  by  increasing  intracranial  pressure,  and  even  where 
death  occurs  earlier,  and  the  only  symptom  of  hydrocephalus  during 
life  has  been  fulness  of  the  fontanelle,  there  is  generally  found  after 
death  to  be  some  dilatation  of  the  ventricles,  the  almost  inevitable 


INFECTIVE   MENINGITIS  193 

result    of    the    adhesive    inflammation    between    the    medulla    and 
cerebellum. 

Another  complication,  which  was  observed  four  times  in  forty 
consecutive  cases,  is  an  inflammation  about  the  joints,  giving  rise  to 
swelling  and  dusky  redness.  The  process  appears  to  be  more  often 
a  periarthritis  than  a  true  arthritis ;  the  exudation  occurs  about  the 
neighbouring  tendon-sheaths  outside  the  capsule  of  the  joint.  It 
has  recently  been  shown  that  this  periarthritis  is  produced  by  a  local 
infection  with  the  same  diplococcus  as  that  found  in  the  meningeal 
exudation. 

Other  accidental  complications,  such  as  diarrhoea  and  broncho- 
pneumonia, are  apt  to  occur  towards  the  end  of  the  illness,  when 
emaciation  and  exhaustion  are  extreme.  "With  these  occasional 
exceptions  the  thoracic  and  abdominal  viscera  are  singularly  free  from 
obvious  disease. 

Prognosis. — The  prognosis  in  this  disease  is  much  more  hopeful 
than  in  tuberculous  or  in  suppurative  meningitis,  pneumococcal  or 
otherwise.  While  it  may  be  doubted  whether  recovery  ever  occurs 
in  these  latter  forms  of  meningitis,  there  is  no  doubt  that  quite  an 
appreciable  proportion,  probably  quite  10  per  cent,  of  the  cases  of 
posterior  basic  meningitis  recover.  There  may  be  complete  recovery, 
but  often  there  remains  some  permanent  damage  to  the  brain, 
resulting  in  some  cases  in  chronic  stationar}-  hydrocephalus,  in 
others  in  idiocy  or  imbecility,  with  or  without  hydrocephalus. 

It  is  noteworthy  that  in  cases  of  recovery  the  blindness  of 
posterior  basic  meningitis  has  disappeared  completely  after  some 
months'  duration.  The  periarthritis  and  arthritis  also  tend  to 
recover  spontaneously. 

The  disease  in  many  cases  proves  fatal  about  five  weeks  after 
the  onset,  but  often  the  fatal  result  does  not  occur  until  the  end  of 
the  third  or  fourth  month  of  the  illness,  and  in  some  cases,  as 
already  mentioned,  the  symptoms  slowly  subside  and  the  child 
recovers. 

The  prognosis  in  any  individual  case  depends  mainly  on  the  age 
of  the  patient — the  younger  the  child  the  less  is  the  chance  of 
recover}- — and  the  severity  of  the  symptoms;  long-continued  pyrexia, 
extreme  head  retraction  and  much  rigidity  of  limbs  are  all  bad 
signs  ]  but  the  gravest  of  all  symptoms  is  the  rapid  supervention  of 
hydrocephalus.  In  cases  that  seem  to  have  recovered  except  for 
the  presence  of  hydrocephalus,  prognosis  must  be  guarded,  for 
although  the  hydrocephalus  may  appear  to  be  stationary,  such  cases 
are  apt  to  die  suddenly  and  quite  unexpectedly. 

vo'..  I  o 


194  MANUAL  OF  MEDICINE 

Diagnosis. — The  disease  with  which  posterior  basic  meningitis 
is  most  likely  to  be  confused  is  tuberculous  meningitis.  The  most 
important  point  of  distinction  is  the  presence  of  head  retraction. 
There  is  often  some  stiffness  of  the  neck  in  tuberculous  meningitis, 
but  anything  like  the  definite  and  often  extreme  head  retraction 
which  characterises  the  posterior  basic  disease  is  very  rare  in 
tuberculous,  and  indeed  in  any  other  form  of  meningitis.  At  the 
beginning  the  diagnosis  may  be  difficult,  but  the  earlier  age,  the 
more  sudden  onset,  the  screaming,  the  absence  of  irregularity  of  the 
pulse,  and  the  absence  of  paralysis  of  cranial  nerves  are  points  in 
favour  of  posterior  basic  meningitis.  Later  on  the  much  slower 
course,  the  persistence  of  vomiting,  contrasting  with  its  more  inter- 
mittent character  in  the  tuberculous  disease,  in  which  vomiting 
often  occurs  only  at  the  beginning  and  at  the  end  of  the  illness,  the 
absence  of  slow  and  irregular  pulse,  and  of  optic  neuritis,  the 
presence  of  blindness,  and  above  all  the  persistent  head  retraction, 
usually  make  the  diagnosis  easy.  Signs  of  tuberculosis  in  other 
parts  of  the  body  would  of  course  favour  the  diagnosis  of  tuberculous 
meningitis. 

From  suppurative  meningitis,  whether  due,  as  most  commonly 
happens,  to  the  pneumococcus  or  to  other  micro-organisms,  the 
posterior  basic  form  can  generally  be  distinguished  clinically  by  the 
absence  of  a  primary  focus  of  infection.  In  suppurative  meningitis 
an  obvious  source  of  infection  is  almost  invariably  present,  by  far  the 
commonest  in  children  being  pneumonia  or  empyema,  or  it  may  be 
otitis  media  or  some  other  infective  disease,  such  as  erysipelas ;  the 
presence  of  such  a  source,  together  with  the  far  more  rapid  course  of 
the  disease,  which  seldom  lasts  more  than  a  few  days,  and  the  absence 
of  head  retraction  would  point  to  suppurative  meningitis.  Between 
epidemic  cerebro-spinal  meningitis  and  posterior  basic  meningitis  the 
clinical  differences  are  but  slight.  The  limitation  of  this  particular 
group  of  symptoms  almost  to  early  infancy,  the  more  chronic  course, 
the  absence  of  the  rash,  especially  of  the  herpes  which  has  charac- 
terised some  epidemics,  the  greater  prominence  of  the  head  retrac- 
tion, the  absence  usually  of  deafness,  of  conjunctivitis,  of  hyperses- 
thesia,  these  are  the  clinical  points  which,  together  with  the  slight 
differences  of  bacteriology  and  morbid  anatomy,  have  been  thought 
to  separate  the  posterior  basic  from  the  epidemic  disease.  Head 
retraction,  it  must  be  remembered,  is  not  always  a  symptom  of 
meningitis ;  reflex  irritation,  sometimes  from  ear  disease,  sometimes 
from  the  teeth,  may  cause  distinct  head  retraction  for  several  days  ;  in 
infants  also  with  pulmonary  and  other  disease,  associated  with  much 


INFECTIVE   MENINGITIS  195 

dyspnoea,  the  head  is  sometimes  considerably  retracted,  probably  for 
the  better  use  of  the  extraordinary  muscles  of  respiration. 

Morbid  anatomy. — The  essential  feature  of  the  disease  is  an 
exudation  of  lymph  in  the  pia-arachnoid  at  the  base  of  the  brain  and 
on  the  spinal  cord.  The  exudation  extends  forward  usually  to  the 
optic  chiasma  and  sometimes  slightly  along  the  Sylvian  fissures,  but 
there  is  very  rarely  any  trace  of  it  on  the  vertex,  which  appears  quite 
normal  except  for  some  flattening  of  the  convolutions  from  the  fluid 
distension  of  the  ventricles,  which  is  almost  always  present. 

The  most  constant  site  of  the  inflammation  at  the  base  is  the 
reflection  of  the  arachnoid  between  the  medulla  and  cerebellum  ;  it 
is  the  inflammation  here  which  determines  some  of  the  clinical 
features  of  the  disease,  especially  the  occurrence  of  hydrocephalus 
from  obstruction  of  the  foramina  of  Majendie  and  of  Luschka,  first 
by  inflammatory  exudation,  and  later  by  adhesions.  The  head  retrac- 
tion also  is  probably  due  to  the  inflammation  in  this  region,  which 
acts  as  a  direct  stimulus  to  the  upper  cervical  nerves,  and  so  produces 
spasm  of  the  muscles  which  they  supply.  But  this  is  not  the  whole 
explanation  of  this  symptom,  for,  as  already  pointed  out,  it  occurs 
also  with  ear  disease  without  meningitis  ;  in  such  cases,  and  probably 
to  some  extent  in  posterior  basic  meningitis,  it  is  to  be  regarded  as 
a  reflex  phenomenon. 

In  cases  where  the  illness  has  lasted  three  or  four  months,  all 
lymph  exudation  has  disappeared,  leaving  only  thickening  and 
adhesions  of  the  pia-arachnoid. 

An  important  feature  in  the  morbid  anatomy  of  posterior  basic 
meningitis  is  the  absence  of  any  obvious  source  of  infection.  The 
rest  of  the  body  is  healthy  except  for  such  accidental  complications 
as  may  happen  towards  the  end  of  any  chronic  disease.  Herein, 
as  already  pointed  out,  it  contrasts  markedly  with  ordinary  suppura- 
tive meningitis. 

Treatment, — No  drug  can  be  said  to  have  any  special  influence 
over  this  disease.  It  has  been  thought  that  occasionally  mercury 
has  had  some  beneficial  effect ;  some  of  the  cases  that  have  recovered 
have  been  treated  with  mercury,  and  it  is  certainly  worthy  of  trial 
either  by  inunction  or  by  internal  administration.  Potassium 
iodide  has  also  been  recommended,  and  may  possibly  hasten 
absorption  of  the  lymph  exudation. 

The  application  of  ice  to  the  head  or  the  nape  of  the  neck,  with 
due  precautions  against  collapse,  seems  to  check  the  vomiting  in 
some  cases,  and  may  have  some  beneficial  influence  on  the  inflamma- 
tion.     Counter-irritants,  if  used  at  all,  must  be  used  with  the  utmost 


ig6  MANUAL  OF  MEDICINE 

caution  ;  the  risk  of  producing  troublesome  sores  on  the  delicate  skin 
of  an  infant  is  hardly  compensated  by  the  doubtful  value  of  this 
method  of  treatment. 

Persistent  vomiting  may  be  very  difficult  to  check  ;  dilute  hydro- 
cyanic acid  in  minute  doses,  a  quarter  to  half  a  minim  for  an  infant 
of  nine  months,  may  be  tried,  but  as  a  rule  no  drugs  will  check  it. 
Nasal  feeding,  which  sooner  or  later  almost  always  becomes  necessary, 
owing  to  the  obstinate  refusal  to  take  nourishment,  may  have  some 
beneficial  effect  on  the  vomiting. 

Every  effort  must  be  made  to  maintain  nutrition  ;  rectal  feeding 
must  be  used  if  necessary,  and  the  diet  must  be  carefully  planned. 
Cod-liver  oil  and  malt  are  useful,  especially  during  the  slow  process 
of  recovery. 

Recently  operative  treatment  has  been  attempted,  chiefly  with  a 
view  to  establishing  drainage  of  the  ventricles,  and  so  preventing  the 
tendency  to  progressive  and  fatal  hydrocephalus.  The  results 
hitherto  have  been  disappointing ;  in  most  cases  death  has  followed 
shortly  after  the  operation,  sometimes  with  sudden  hyperpyrexia ;  in 
at  least  one  case,  however,  the  operation  has  been  successful. 

Puncture  of  the  membrana  tympani  on  both  sides  is  advisable 
in  doubtful  cases,  where  there  is  any  suspicion  that  the  symptoms 
may  be  reflex  in  origin  or  due  to  the  secondary  meningitis  of  ear 
disease. 

The  arthritis  and  periarthritis  tend  to  disappear  spontaneously ; 
they  should  be  treated  by  simple  warm  applications. 

G.  F.  Still. 


Suppurative  Meningitis 

Suppurative  meningitis,  by  which  is  meant  a  purulent  exudation 
in  the  pia-arachnoid  of  the  brain  and  spinal  cord,  occurs  under  two 
conditions — the  first,  and  by  far  the  commonest,  as  a  complication  of 
some  other  infective  disease  ;  the  second,  very  rare,  as  a  primary 
disease.  The  advance  of  bacteriology  has  made  it  evident  that 
many,  perhaps  most  of  the  cases  of  supposed  primary  suppurative 
meningitis,  should  be  regarded  as  sporadic  instances  of  so-called 
epidemic  cerebro- spinal  meningitis,  being  due  to  the  specific 
micro-organism  of  that  disease,  namely  the  diplococcus  intracellularis. 
There  still  remain,  however,  rare  cases  in  which  an  apparently 
primary  infection  is  produced  by  other  micro-organisms. 

Some  confusion   has   been  introduced  into   this  subject  by  the 


INFECTIVE  MENINGITIS  197 

attempt  to  classify  cases  of  acute  meningitis  according  to  their 
anatomical  distribution  ;  in  this  way  suppurative  meningitis  has  been 
distinguished  as  "  vertical,"  and  the  epidemic  disease  has  been 
called  "  cerebro- spinal "  ;  but  it  must  be  clearly  understood  that 
any  form  of  meningitis  may  be,  and  often  is,  cerebro-spinal  in  dis- 
tribution, and  suppurative  meningitis,  though  it  tends  to  affect  the 
vertex  first  and  chiefly,  may  nevertheless  be  limited  to  the  base  and 
spinal  cord. 

The  ideal  basis  of  classification  is  the  bacteriological,  but  in  the 
present  state  of  our  knowledge  no  complete  cUnical  differentiation 
on  the  same  fines  is  possible,  so  that  for  practical  purposes  it  is 
convenient  to  group  together  under  the  head  of  suppurative  men- 
ingitis those  cases  of  acute  leptomeningitis  which,  although  infective 
in  character,  do  not  fall  into  clinical  groups  corresponding  with 
their  bacteriological  differences,  as  happens  in  the  epidemic,  the 
posterior  basic,  and  the  tuberculous  forms. 

Etiology. — Suppurative  meningitis  is  most  common  in  infancy, 
but  it  occurs  at  all  ages.  There  is  no  marked  difference  in  the 
frequency  with  which  the  two  sexes  are  affected.  No  particular 
seasonal  variation  has  been  observed,  except  in  so  far  as  the 
meningitis  follows  the  seasonal  curve  of  the  infective  conditions 
with  which  it  is  associated ;  the  pneumococcal  cases  for  this  reason 
are  commoner  in  winter  and  spring  than  at  other  times. 

Suppurative  meningitis  occurs  most  often  as  a  complication  of 
pneumonia  or  empyema.  The  next  most  frequent  cause  is  bone 
disease  in  connection  with  the  ear.  It  occurs  also  as  a  complication 
of  several  infective  diseases,  especially  erysipelas  and  pyaemia,  includ- 
ing under  the  latter  head  malignant  endocarditis ;  rarely  it  com- 
plicates smallpox,  scarlatina,  typhoid,  and  influenza,  and  still  more 
rarely  it  has  been  seen  in  cases  of  nephritis ;  but  in  all  these 
conditions  it  may  be  rather  a  sequela  than  a  complication,  and  it  is 
certain  that  sometimes  at  least  in  such  cases  the  meningitis  is  not 
due  to  the  same  virus  as  the  primary  disease,  but  is  pneumococcal 
or  streptococcal  in  character,  and  is  secondary  to  some  pneumococcal 
or  streptococcal  lesion  elsewhere,  to  w^hich  the  primary  disease 
predisposed.  It  may  be  due  also  to  injury  ;  sometimes  it  results 
from  disease  of  the  nasal  cavities ;  and  in  infants  a  not  very  rare 
cause  is  sloughing  of  the  skin  over  a  spina  bifida. 

Bacteriology. — The  micro-organism  most  commonly  found  in 
the  meningeal  exudation  is  tht  pneufnococais.  In  children  fully  two- 
thirds  of  the  cases  are  due  to  the  pneumococcus.  This  micro- 
organism also  would  seem  to  be  the  usual  cause  of  the  meningitis  in 


198  MANUAL   OF   MEDICINE 

the  very  rare  cases  where  this  disease  is  primary.  Where  meningitis 
occurs  as  a  complication  of  erysipelas  or  pyoemia  the  streptococcus  is 
often  found  in  the  exudation,  while  in  cases  secondary  to  disease  of 
the  petrous  bone  a  mixed  infection  is  usually  found,  streptococcus 
pyogenes,  and  staphylococcus  aureus  or  albus  being  present  sometimes 
with  bacillus  coli  cot?i/nums  and  sometimes  with  the  pneumococcus 
also.  In  some  cases,  even  where  the  primary  source  of  infection  is 
pneumococcal,  and  cultures  from  the  meningeal  exudation  show  an 
almost  pure  growth  of  the  pneumococcus,  the  streptococcus  pyogenes, 
or  staphylococcus  albus  or  aureus  is  found  to  be  present  also,  mixed 
infection  having  occurred.  Cases  have  been  reported  in  which  the 
influenza  bacillus  or  the  typhoid  bacillus  have  been  found  in  the 
meningeal  exudation,  where  meningitis  occurred  as  a  complication 
of  influenza  or  of  typhoid  fever. 

Symptoms. — In  many  cases,  especially  in  infants,  when  the 
patient  is  already  severely  ill  with  the  primary  disease,  the  onset  of 
suppurative  meningitis  is  obscured  by  the  previous  symptoms,  and 
this  complication  may  even  be  entirely  unsuspected  until  post- 
mortem examination  reveals  its  presence. 

More  often,  however,  vomiting  and  convulsions  occur  at  the 
onset,  and  in  older  children  and  adults  delirium  may  be  a  marked 
feature.  Sometimes  from  the  beginning  there  is  stupor,  which 
gradually  deepens  into  coma  after  a  few  days. 

Headache  is  severe,  and  even  when  the  patient  is  semicomatose 
the  fades,  with  its  anxious  expression  and  knitting  of  the  eyebrows, 
often  suggests  the  continuance  of  pain.  Retraction  of  the  head  is 
occasionally  present,  but  is  much  less  marked  than  in  posterior  basic 
meningitis. 

Bulging  of  the  anterior  fontanelle  is  an  early  symptom  in  infants. 

A  fine  tremor  of  the  limbs,  especially  on  movement,  is  often 
noticed  quite  early  in  the  disease ;  paralysis  of  one  or  more  limbs  is 
sometimes  present,  and  towards  the  end  of  the  disease  there  is  often 
rigidity. 

Paralysis  of  cranial  nerves  is  more  common  than  in  the  posterior 
basic  disease ;  squint  is  usually  present.  Slight  nystagmus  is  some- 
times seen,  but  much  less  often  than  in  posterior  basic  meningitis. 
Optic  neuritis  is  often  associated  with  suppurative  meningitis,  but  by 
no  means  always. 

Vomiting  is  generally  frequent  throughout;  the  bowels  are  costive. 
The  pulse  and  respiration  are  rapid  and  often  irregular ;  the  latter 
may  be  of  Cheyne-Stokes'  character.  The  temperature  is  usually 
highj  but  sometimes  becomes  subnormal  towards  the  end. 


INFECTIVE  MENINGITIS  199 

Diagnosis. — It  will  be  seen  that  in  many  of  its  symptoms 
suppurative  meningitis  resembles  other  forms  of  meningitis,  and 
sometimes  indeed  the  diagnosis  is  extremely  difficult.  There  are, 
however,  two  points  which  ser\-e  to  differentiate  the  suppurative  form, 
both  from  the  posterior  basic  disease  and  from  tuberculous 
meningitis :  first,  its  rapid  course ;  suppurative  meningitis  is  a 
disease  of  a  few  days,  the  onset  of  symptoms  is  sudden,  their  course 
is  rapid :  secondly,  the  presence  of  a  source  of  infection,  whether  it 
be  some  local  disease,  such  as  empyema  or  ear  disease,  or  some 
general  disease,  such  as  pyaemia.  Where  symptoms  of  meningitis 
are  associated  with  such  a  source  of  infection,  and  prove  fatal  in  less 
than  a  week,  the  diagnosis  of  suppurative  meningitis  is  almost 
certain.  From  sporadic  cases  of  the  epidemic  cerebro-^pinal  disease, 
suppurative  meningitis  is  usually  distinguished  by  the  presence  of 
some  obvious  source  of  infection,  but  in  the  rare  cases  of  primary 
suppurative  meningitis,  where  this  point  of  distinction  is  lacking,  the 
diagnosis  may  be  impossible.  Perhaps  the  presence  of  herpes  or  of 
a  purpuric  rash  may  point  to  the  "  epidemic  "  disease ;  certainly  the 
prolongation  of  the  illness  beyond  the  tenth  or  eleventh  day  would 
be  strongly  against  suppurative  meningitis,  but  in  most  cases  the 
only  possible  method  of  diagnosis  is  a  bacteriological  examination, 
and  it  may  therefore  be  advisable  in  rare  cases  to  make  use  of 
lumbar  puncture. 

In  connection  with  ear  disease  there  is  often  some  difficulty  of 
diagnosis,  for,  on  the  one  hand,  cerebral  abscess  may  closely  simulate 
suppurative  meningitis,  and  on  the  other  hand  the  meningitis  which 
complicates  ear  disease  is  by  no  means  always  suppurative ;  in  many 
cases  it  is  tubercular.  Cerebral  abscess  may  be  distinguished  by 
its  slower  course,  a  normal  or  subnormal  temperature,  unilateral 
paralysis,  sometimes  aphasia,  and  in  rare  cases  localised  tenderness, 
but  even  such  symptoms  may  be  deceptive,  for  it  sometimes 
happens,  especially  with  ear  disease,  that  suppurative  meningitis 
remains  for  some  time  quite  a  localised  process  and  may  thus  give 
rise  to  hemiplegic  symptoms. 

In  tuberculous  meningitis  the  onset  is  more  gradual ;  the  course 
is  much  slower;  the  temperature  is  generally  lower  than  in  the 
suppurative  form ;  tache  cerebrale,  retraction  of  the  abdomen,  and 
slowness  of  the  pulse,  with  irregularity,  are  more  marked  symptoms. 

Prognosis. — In  suppurative  meningitis,  whether  secondary  or 
primary,  the  prognosis  is  very  bad.  There  is  reason  to  believe 
that  some  cases  of  localised  suppurative  leptomeningitis  in  con- 
nection with  ear  disease  have  recovered  where  early  operation  has 


200  MANUAL  OF  MEDICINE 

been  performed,  but  with  this  exception  it  is  doubtful  whether  re- 
covery ever  occurs.  It  must  be  understood  that  no  reference  is  made 
here  to  those  sporadic  cases  of  cerebro-spinal  meningitis  in  which 
the  diplococcus  intracellularis  is  found ;  these  are  included  under 
the  head  of  epidemic  cerebro-spinal  meningitis  and  have  a  much 
more  favourable  prognosis.  Suppurative  meningitis  is  usually  fatal 
in  less  than  a  week.  The  fatal  result  is  very  rarely  delayed  beyond 
the  tenth  day. 

Morbid  anatomy. — In  very  acute  cases,  where  death  has 
occurred  within  a  day  or  two  of  the  onset  of  the  meningitis,  the 
only  abnormal  appearance  on  the  brain  may  be  some  excess  of 
almost  clear  fluid  in  the  pia-arachnoid,  giving  it  a  watery  oedema- 
tous  appeara'^ce,  while  at  the  same  time  there  is  some  undue 
vascularity  of  the  meninges,  and  perhaps  a  trace  of  grayish  opacity 
along  the  vessels  in  the  sulci.  To  this  condition  some  observers 
have  given  the  name  of  "  serous  meningitis."  It  differs  only  in 
degree  from  the  later  stages,  in  which  the  grayish  opacity  along  the 
vessels  becomes  first  yellowish  exudation,  then  definitely  purulent, 
until,  in  the  most  advanced  cases  a  continuous  sheet  of  greenish- 
yellow  pus  in  the  pia-arachnoid  covers  the  whole  surface  of  the 
brain.  In  many  cases  the  exudation  is  most  marked  over  the 
anterior  two-thirds  of  the  vertex,  but  it  is  seldom  limited  to  the 
vertex.  In  most  cases  the  base  also  is  affected.  Sometimes  only 
a  patch  of  purulent  exudation  is  seen  on  the  inferior  surface  of 
each  temporo-sphenoidal  lobe,  but  often  the  whole  base  is  covered 
almost  as  thickly  as  the  vertex.  The  spinal  cord  seldom  escapes ; 
the  posterior  surface,  especially  in  the  lumbar  region,  is  affected 
earliest;  later  the  whole  cord  is  covered  with  exudation. 

Although  the  mflammation  is  mainly  in  the  meninges,  it  must 
not  be  forgotten  that  there  is  certainly  in  many  cases,  if  not  in  all, 
some  extension  of  the  inflammadon  to  the  brain  substance  beneath, 
and  in  some  cases  this  can  even  be  appreciated  by  the  naked  eye 
as  undue  redness  and  vascularity  of  the  superficial  brain  substance, 
which  may  show  minute  ecchymoses  or  even  minute  points  of  pus 
on  section. 

Rarely  the  meningitis  is  the  only  discoverable  lesion,  but  in 
most  cases,  as  already  pointed  out,  some  primary  lesion  is  found 
elsewhere.  In  children  this  is  usually  empyema  or  thick  l3^mph 
on  the  pleura,  and  it  is  not  uncommon  to  find  associated  with  the 
meningitis,  in  addition  to  the  pleurisy,  a  purulent  or  sero-purulent 
pericarditis,  and  sometimes  also  peritonitis. 

Treatment. — The   only  cases  in  which  treatment  is  likely  to 


INFECTIVE   MENINGITIS  201 

be  of  much  avail  are  those  in  which  meningitis  is  secondary  to  ear 
disease.  Early  surgical  treatment  in  such  cases  has  been  success- 
ful, but  it  seems  likely  that  where  such  a  favourable  result  has 
occurred  only  a  limited  area  of  the  pia-arachnoid  has  been  affected. 
Operation  is  probably  useless  where  the  meningitis  has  already 
become  generalised. 

There  can,  however,  be  little  doubt  that  much  may  be  done  in 
the  way  of  prophylaxis.  Careful  antisepsis  and  timely  operative 
measures  in  the  treatment  of  otitis  media  would  do  much  to  reduce 
the  mortality  from  suppurative  meningitis.  In  empyema  also,  and 
suppurative  pericarditis,  any  delay  in  operation  probably  increases 
the  risk  of  meningitis.  So  long  as  pus  or  thick  lymph  is  pent  up 
in  the  pleural  or  the  pericardial  cavity  there  is  a  virulent  culture 
of  pneumococcus  or  other  micro-organisms,  which  may  at  any 
moment  give  rise  to  a  secondary  infection  of  the  meninges.  It  is 
important  also  to  remember  that  even  where  an  empyema  has 
been  already  opened  a  separate  collection  of  pus,  perhaps  only  a 
drachm  or  two,  may  remain  shut  off  by  pleural  adhesions,  or  en- 
closed in  the  mediastinal  connective  tissue,  and  such  small  collec- 
tions may  serve  as  the  focus  of  infection  from  which  a  suppurative 
meningitis  may  result. 

The  treatment  of  suppurative  meningitis  in  those  cases  which 
appear  to  be  primar}-,  or  are  not  amenable  to  surgical  treatment, 
resolves  itself  mainly  into  the  treatment  of  symptoms,  particularly 
the  alleviation  of  pain.  For  this  purpose  the  application  of  an 
ice-bag  to  the  head  or  of  leeches  behind  the  ears  may  be  tried ;  if 
these  fail  morphia  should  be  administered.  Nasal  or  rectal  feeding 
will  probably  be  necessarj'.  In  cases  where  there  is  great  collapse 
and  prostration  early  in  the  disease,  as  sometimes  happens,  stimu- 
lants, such  as  strychnine  or  alcohol,  may  be  required,  and  hot-water 
bottles  may  be  placed  in  the  bed ;  but  in  this,  as  in  other  forms  of 
meningitis,  the  patients  often  show  a  curious  tendency  to  blister- 
wi:h  the  application  of  a  degree  of  heat  which  would  be  quite 
innocuous  in  other  diseases. 

The  use  of  antitoxic  serum,  either  anti-pneumococcic  or  anti- 
streptococcic, according  to  the  probable  nature  of  the  infection,  is 
worthy  of  trial,  but  there  is  not  at  present  sufficient  experience  to 
show  how  far  such  treatment  may  be  of  value. 

G.  F.   Still. 


MANUAL  OF   MEDICINE 


INFLUENZA 


Few  diseases  manifest  themselves  under  guises  so  varied  as 
influenza.  Hardly  an  organ  or  system  of  the  body  that  may  not 
be  its  victim ;  hardly  a  symptom  or  subjective  sensation  it  has  not 
awakened.  This  almost  infinite  variety  of  manifestations  not  only 
makes  diagnosis  difficult,  but  leads  to  many  obscure  conditions 
being  ascribed,  without  adequate  evidence,  to  influenza,  which  has, 
so  to  speak,  become  the  last  resource  of  the  baffled  diagnostician. 
There  are  certain  broad  types  of  the  disease  which  may  be  thus 
described : — 

I.  The  simple  type. — Here  with  suddenness  occur  the  chilli- 
ness of  fever,  severe  pains  in  the  head,  back,  and  limbs,  rapidly 
followed  by  great  nervous  prostration.  The  face  is  flushed  and  the 
conjunctivae  suff'used ;  the  tongue  is  tremulous,  indented,  moist,  and 
covered  by  a  dirty  white  fur ;  the  breath  is  foetid.  On  examining  the 
throat,  the  posterior  pharyngeal  wall  is  found  red,  injected,  and  often 
dry,  the  tonsils  red  and  angry-looking,  but  not  appreciably  swollen ; 
less  often  they  are  enlarged  and  their  follicles  plugged,  as  in  a  case 
of  scarlet  fever  or  tonsillitis.  The  pulse  beats  90  or  100  to  the 
minute — an  acceleration  moderate  in  proportion  to  the  symptoms, 
and  is  soft  and  compressible,  and  liable  to  become  dicrotic.  The 
respiration  is  but  slightly  increased.  There  is  either  no  cough  or 
one  that  is  dry  and  irritable,  and  having  its  origin  in  the  throat  and 
trachea.  There  are  no  abnormal  physical  signs  in  chest  or  abdomen. 
The  skin  is  hot  and  dry  to  begin  with,  but  later  there  is  often 
profuse  sweating.  The  urine  is  febrile.  The  pain  in  the  head  is 
severe,  and  on  any  attempt  at  movement  is  well-nigh  unbearable ; 
the  eyeballs  ache.  The  pains  in  the  limbs  are  more  marked  in  the 
legs  than  in  the  arms ;  the  muscles  and  tendons  are  often  ex- 
cessively tender  on  manipulation,  and  the  skin  hypersesthetic.  The 
joints  are  neither  swollen  nor  more  tender  than  the  condition  of 
the  periarticular  structures  will  account  for.  The  patient  aches 
everywhere  as  if  bruised,  and  in  no  position  can  comfort  be 
obtained.  He  is  restless  and  unable  to  sleep,  except  fitfully,  and  at 
times  there  is  delirium.  Further  there  is  added  an  indescribable 
misery  and  depression,  the  whole  constituting  a  feeling  of  illness 
which  life  could  not  endure,  but  for  a  brief  space.  The  character 
of  such  an  attack  extends  usually  from  two  to  five  days,  then  the 


INFLUENZA  203 

temperature,  which  has  varied  from  100  to  103,  or  higher,  falls  to 
normal,  or  below  it. 

2.  In  the  PULMONARY  TYPE  the  disease  is  ushered  in  with  the 
same  symptoms  of  chilliness,  fever,  pains  and  prostration,  but  cough 
and  embarrassed  breathing  early  become  prominent  features.  The 
cough  is  dry,  especially  troublesome  at  night,  and  exceedingly 
harassing — no  cough  more  so ;  it  will  sometimes  last  almost 
continuously  for  an  hour  or  more  at  a  time,  draining  the  patient's 
strength  to  the  point  of  utter  exhaustion.  It  may  persist  for  weeks 
after  the  acute  symptoms  have  subsided.  The  sputum  is  very  scanty 
and  tenacious,  or  may  at  first  be  quite  absent.  As  the  case 
progresses  it  will  become  rather  more  plentiful  and  change  from  the 
mucoid  and  translucent  to  the  muco-purulent  and  opaque,  but  it 
often  remains  extremely  sticky  and  tenacious,  despite  all  efforts  of 
treatment  to  loosen  it. 

The  physical  signs  are  slight  in  proportion  to  the  severity  of  the 
symptoms  and  depend  on  the  distribution  and  extent  of  the  lung 
trouble.  If  the  mischief  is  bronchial  and  confined  to  the  larger  and 
medium -sized  tubes,  the  symptoms  are  milder  than  when  it  is 
broncho-pneumonic  with  the  smaller  tubes  and  alveoli  involved. 
The  more  severe  pneumonic  condition  is  denoted  by  more  rapid 
breathing,  a  weak  rapid  pulse  of  120  or  more,  duskiness  of  the  face, 
greater  prostration.  The  physical  signs  of  this  influenzal  broncho- 
pneumonia are  peculiar  and  ill-defined,  and  in  their  absence  of 
clearness  and  distinctness  stand  out  in  contrast  with  the  definite 
signs  of  lobar  pneumonia.  The  first  feature  to  claim  attention  is 
a  marked  diminution  of  breath  sounds,  especially  over  the  backs  of 
the  lungs,  and  a  short,  highly  pitched,  sticky  rale,  which  is  character- 
istic and  conveys  the  same  idea  to  the  sense  of  hearing  that  the 
glutinous  sputum  does  to  the  sense  of  sight.  These  special  rales 
may  often  be  brought  out  after  coughing,  over  spots  where  the  only 
sign  before  was  diminished  or  absent  breath  sounds.  There  is  a 
general  impairment  of  resonance,  more  marked  in  some  places  than 
others,  but  no  clearly  defined  area  of  dulness.  Vocal  resonance  and 
tactile  vocal  fremitus  are  modified  in  no  very  helpful  or  constant 
way,  but  are  diminished  more  often  than  increased.  There  may  be 
here  and  there  a  patch  of  bronchial  breathing,  but  it  does  not 
stand  out  as  a  usual  or  prominent  sign.  The  next  strikingly 
characteristic  feature  of  these  phenomena  is  the  way  in  which  they 
extend  and  change  their  distribution.  Manifesting  themselves 
more  prominently  at  the  bases,  they  creep  from  one  part  of  the 
chest  to  another ;  perhaps  one  area  will  improve  only  for  another 


2  04  MANUAL  OF   MEDICINE 

to  be  affected,  or  if  one  lung  shows  signs  of  improvement  the 
other  shows  those  of  deeper  involvement.  It  is  this  uncertainty  as 
to  the  length  of  the  illness,  with  its  constant  strain  on  the  patient's 
strength,  that  makes  this  form  of  influenza  so  discouraging  and 
anxious.  If  the  case  is  tending  towards  a  fatal  issue  the  above 
signs  extend  over  wider  and  wider  areas  of  lung,  but  do  not  alter 
their  features.  At  the  same  time  the  breathing  becomes  more 
rapid  and  shallow,  the  patient  more  distressed,  and  it  may  be 
delirious,  the  fever  increases,  the  face  appears  more  dusky,  a  semi- 
comatose condition  supervenes,  and,  quickly  following  it,  the  end. 

3.  The  abdominal  type. — This  form  of  influenza  has  been 
prominent  in  many  less  severe  epidemics  and  is  present  in  most. 

The  fever  is  moderate — often  not  above  100°  F.  The  attack 
is  characterised  by  the  same  suddenness  of  onset,  and  the  same 
depression  and  prostration  as  in  the  former.  Acute  abdominal  pain 
usually  begins  the  illness  and  is  followed  by  vomiting,  and  in  some 
cases  by  diarrhoea  as  well.  Anorexia  is  complete.  Such  an  attack 
is  often  at  first  difficult  to  distinguish  from  other  causes  of  acute 
abdominal  pain,  such  as  intestinal  colic,  gall-stone  colic,  gastralgia, 
and  even  peritonitis,  but  head  or  back  pains,  a  sore  throat  or  a 
cough  make  the  true  nature  of  the  illness  evident. 

Course. — In  no  disease  is  the  course  of  an  attack  so  difficult  to 
foresee.  Fortunately  a  goodly  proportion  of  the  cases  are  moderate 
in  severity  and  simple  in  type,  and  after  three  or  four  days  of  fever, 
headache,  etc.,  the  temperature  will  fall  to  subnormal,  and  the 
patient,  feeling  bruised  and  shattered,  will  slowly  recover  strength. 
No  doubt,  as  with  other  specific  diseases,  there  are  slight,  almost 
abortive,  attacks,  which  run  an  even  shorter  course.  Frequently 
symptoms  will  continue  after  the  temperature  has  subsided,  and  this 
disproportion  between  the  degree  of  pyrexia  and  the  state  of  the 
patient  is  a  characteristic  feature.  Or  the  temperature  may  keep 
up  for  two,  three,  or  even  more  weeks,  and,  although  the  acute 
pains  may  go,  the  feehng  and  evidences  of  "  illness "  remain, 
perhaps  creating  doubt  as  to  whether  the  case  is  not  one  of 
typhoid  fever.  Or  what  may  begin  with  a  simple  attack  will  pass 
on  into  influenzal  bronchitis  or  broncho-pneumonia,  either  directly, 
or  in  the  form  of  relapse  after  a  brief  interlude  of  normal  tempera- 
ture ;  and,  as  already  stated,  this  form  of  pneumonia  is-  often 
very  long-abiding.  The  clinical  forms  of  the  disease  as  described 
are  not  always  sharply  demarcated,  but  may  follow  or  accompany 
each  other. 

Special  symptoms,  complications,  and  sequelsa—Jlfod/^^ 


INFLUENZA  205 

(ations  of  the  iemperaiure. — All  varieties  of  curve  may  be  met  v,  itb. 
Frequently  highest  at  the  onset,  the  acme  may  not  be  reached  for 
several  days.  For  some  time  the  fever  may  be  of  a  regularly  inter- 
mittent type,  accompanied  by  shivering  or  rigors,  and  followed  by 
sweating — presenting  a  malariform  character ;  or  the  greatest  variety 
may  be  exhibited  from  day  to  day,  occasionally  the  highest  point 
being  reached  in  the  early  hours.  Now  and  then  cases  run  their 
course  with  no  rise  of  temperature — an  apyrexial  influenza.  In  such 
there  is  great  prostration  and  depression,  a  subnormal  temperature 
of  96-97°  F.,  no  acute  pains,  but  a  feeling  of  great  illness  and  a 
sensation  of  sinking  through  the  bed,  a  misery  that  defies  descrip- 
tion, and  an  utter  inability  to  even  hope  or  try  to  get  better 
constituting  a  form  of  the  disease  perplexing  to  recognise,  and  one 
that  recovers  slowly  and  with  difficulty.  This  occasional  absence  of 
fever  recalls  a  similar  and  more  frequent  feature  of  diphtheria. 
Or,  on  the  other  hand,  hyperpyrexia  may  set  in,  and  this  has 
been  more  particularly  noticed  in  cases  marked  by  severe  cerebral 
complications. 

Pulmonary  complications. — Whilst  the  incidence  of  the  disease 
specially  tends  to  the  respiratory  passages,  some  part  or  other  of 
which  rarely  escapes, — though  the  most  prominent  symptoms  may  be 
connected  with  other  organs, — the  greatest  variety  exists  in  the  extent 
to  which  the  several  regions  of  the  tract  may  be  involved.  The 
general  nature  of  the  affection  is,  primarily  at  least,  that  of  a  dry 
catarrh,  often  of  very  partial  and  limited  distribution,  with  ill-defined 
physical  signs. 

The  soil  of  the  influenzal  bacillus  is  congenial  to  that  of  the 
pneumococcus,  and  lobar  pneumonia  will  often  supervene  in  a  case 
of  influenza ;  pleurisy  and  empyema,  the  latter  due  to  secondary 
streptococcal  infection,  are  also  met  with.  Influenza  may  awaken  or 
reawaken  phthisis.  Gangrene,  fibrosis  of  lung,  bronchiectasis,  all 
may  have  their  origin  in  an  attack  of  influenza. 

Cardio-vascularco?nplications. — Influenzal,  like  diphtheritic  cardiac 
affections,  for  the  most  part  have  their  origin  in  some  vice  of  the 
controlling  nerve  mechanism  which  is  due  to  the  influenzal  toxines ; 
thus  tachycardia  and  irregularity  of  rhythm  are  both  late  effects  of 
influenza,  and  may  last  for  very  many  months ;  or  the  pulse  may  be 
markedly  slowed  in  the  later  stages.  Acute  dilatation  of  the  heart 
may  develop  during,  or  at  what  is  apparently  the  end  of,  an  attack ; 
it  manifests  itself  subjectively  by  faintness  and  extreme  weakness, 
and  objectively  by  pallor,  displacement  of  the  apex  beat,  a  rapid, 
irregular,  and  feeble  heart  action   and  pulse.      It  is   always   a  grave. 


2o6  MANUAL  OF  MEDICINE 

though  fortunately  rare,  occurrence,  and,  as  in  acute  rheumatism, 
may  be  attributed  to  the  direct  effect  of  the  toxin  on  the  myocardium. 
Pericarditis  is  sometimes  met  with.  There  are  grounds  for  think- 
ing that  influenza,  although  not  a  cause  of  endocarditis,  yet  favours 
in  some  way  the  development  of  ulcerative  endocarditis. 

Phlebitis  and  thrombosis  of  veins. — In  the  cases  met  with, 
the  lower  extremities  are  most  often  the  seat,  and  the  usual 
manifestations  of  pain,  tenderness  along  the  affected  vein,  and 
swelling  are  present,  with  the  same  obstinate  slowness  of  recovery. 
Thrombosis  of  arteries,  especially  the  popliteal,  with  subsequent 
gangrene  of  the  limb,  has  been  recorded. 

Epistaxis,  melsena,  haematemesis,  hcematuria,  and  menorrhagia 
are  examples  of  bleeding  from  mucous  surfaces,  and  purpura  has 
been  frequently  observed,  either  alone  or  in  conjunction  with  other 
rashes.  It  may  be  noted  that  these  bleedings  are  sometimes 
severe. 

(Edema,  general  or  confined  to  the  lower  extremities,  not  owing 
its  origin  to  the  condition  of  the  heart  or  kidneys  or  to  thrombosis, 
is  occasionally  a  late  effect.  It  varies  considerably  in  degree  from 
time  to  time,  and  may  last  many  months.  Its  pathology  is  obscure, 
but  is  apparently  toxic  in  origin. 

Digestive  disturbances. — Although  clinically  it  is  convenient  to 
refer  to  an  abdominal  type  of  the  disease,  there  are  rarely,  if  ever,  to 
be  met  with  structural  changes  comparable  to  those  found  in  the 
respiratory  organs.  The  usual  phenomena  met  with  are  anorexia, 
furred  tongue,  foul  breath,  constipation,  or  oftener  diarrhoea,  and 
not  unfrequently  vomiting.  If  the  gastro-intestinal  symptoms  be 
severe,  and  especially  if  certain  of  the  nervous  complications  develop, 
the  resemblance  to  typhoid  fever  may  be  marked.  Parotitis  is  of 
occasional  occurrence.  Jaundice,  varying  from  the  slightest  tinting 
of  the  conjunctivae  to  a  general  definite  staining  of  the  skin,  has 
been  noticed,  with  urobilinuria. 

Spleen  and  lymphatic  glands. — An  enlargement  of  the  spleen  is 
sometimes  noticed. 

Besides  the  tonsillar  glands,  which  are  usually  swollen  and  tender 
when  the  throat  is  involved,  it  is  not  unfrequent  to  find  a  more 
general  enlargement  of  the  glands  of  the  neck,  and  even  rarely  of 
other  parts  of  the  body. 

Nervous  systetn. — The  headache,  frontal  or  general,  and  pain  in 
the  back,  which  characterise  the  onset  of  the  disease  in  most  cases, 
may  attain  an  extreme  degree.  Insomnia  also  is  frequent  and  dis- 
tressing, and  may  persist  long  after  other  symptoms  have  subsided, 


INFLUENZA  207 

whilst  delirium  is  not  uncommon  during  the  febrile  stage.  Vertigo 
is  a  feature  of  some  cases.  Loss  of  taste  and  smell  are  sometimes 
complained  ot. 

Neuralgia  is  often  severe  and  lasting.  It  is  widely  distributed, 
and  only  occasionally  localised  to  the  courses  of  particular  nerves. 
Myalgia,  particularly  of  the  thighs  and  calves,  is  frequent.  These 
pains  are  in  large  measure  due  to  the  condition  of  the  nerve 
centres,  degrees  of  peripheral  irritation,  which  in  health  would  pass 
unheeded,  being  brought  up  into  consciousness  and  producing 
pain. 

Neural  troubles  resembling  organic  disease  either  of  the  peripheral 
nerves,  or  of  the  spinal  or  cerebral  centres,  are  common.  Nervous 
symptoms,  which  at  their  inception  perhaps  suggest  neuritis  or 
myelitis,  often  prove  to  be  caused  by  a  functional  toxic  poisoning. 
At  the  same  time  neuritis,  either  multiple  or  local,  does  occur  in  the 
course  of  influenza,  as  in  that  of  diphtheria,  typhoid,  and  other 
microbic  diseases.  It  is  not  selective,  and  shows  no  special  bias 
for  any  particular  group  of  muscles,  like  the  diphtheritic  form  for 
the  palate,  and  the  alcoholic  and  lead  varieties  for  the  extensor 
muscles  of  the  wrist  and  ankle. 

Meningitis  and  myelitis,  either  local  or  diffused,  are  also  among 
the  rare  effects,  but  may  be  due  to  a  mixed  infection. 

Beyond  these  more  easily  defined  effects,  influenza  will  leave  the 
nervous  system  bankrupt  and  exhausted.  Weariness  of  the  body 
and  mind  make  all  effort  irksome  and  difficult ;  memory  is  bad, 
ability  to  think  enfeebled,  and  there  is  an  absence  of  that  initiative 
and  spontaneous  desire  to  be  up  and  doing  which  is  so  strong  a 
feature  of  health.  The  enforced  idleness  brings  with  it  no  sense  of 
ease  or  repose,  and  the  patient  feels  gloomy  and  depressed.  It  is 
common  to  meet  examples  of  people  who,  without  having  any  illness 
that  can  be  labelled,  have  for  ever  been  ailing  since  an  attack  of 
influenza.  Their  power  to  stand  up  against  the  wear  and  tear  of 
life  seems  gone,  and  they  threaten  to  become  a  burden  to  themselves 
and  to  others.  Passing  to  certifiable  insanity,  melancholia,  with  or 
without  delusions,  is  by  far  the  most  common,  and  next  to  this 
is  mania. 

Otitis  media. — This  may  appear  with  but  slight  warning.  A 
sore  throat  is  followed  by  intense  ear-ache,  which  is  often  not 
relieved  till  the  membrana  tympani  bursts,  and  pus  is  discharged. 
The  condition  will  slowly  improve,  or  may  pass  into  a  chronic 
condition. 

Numerous  affections  of  the  eye  may  com.plicate  influenza;  amonn; 


2o8  MANUAL  OF  MEDICINE 

those  of  more  frequent  occurrence  are  conjunctivitis,  keratitis,  and 
various  ocular  neuroses. 

Skin  affections. — Erythematous,  urticarial,  herpetic,  purpuric, 
and  rarely  bullous  eruptions,  will  make  their  appearance  during  the 
height  of  an  attack,  or  during  early  convalescence.  The  erythematous 
rashes  are  the  most  common,  and  may  be  difficult  to  distinguish 
from  those  of  scarlet  fever  or  measles. 

Renal  complications. — A  trace  of  albumen  in  the  urine  is  not  un- 
common. A  large  quantity  of  albumen,  with  or  without  hccmaturia, 
may  be  present ;  sometimes  it  is  accompanied  by  oedema  and 
denotes  nephritis,  but  more  often  it  does  not.  Glycosuria  is  of 
occasional  occurrence. 

Orchitis  sometimes  arises,  and  it  is  said  to  do  so  in  conjunction 
with  parotitis. 

Arthritic  affections  are  rare,  but  met  with.  Influenza  predisposes 
to  rheumatoid  arthritis. 

The  exceedingly  wide  range  of  manifestation  here  set  forth 
confers  the  multiform  character  on  the  disease.  How  far  all  these 
phenomena  are  to  be  regarded  as  essentials  of  the  malady,  and 
directly  attributable  to  the  causal  microbe  is  doubtful  and  the 
possibility  of  mixed  infection  should  not  be  lost  sight  of. 

Diagnosis. — Owing  to  its  many-sidedness,  influenza  often  pre- 
sents difficulties  in  diagnosis.  At  its  inception  the  high  temperature 
and  the  onset  might  well  suggest  measles,  scarlet  fever,  or  pneumonia, 
or  other  specific  fevers. 

Where  the  characteristic  rash  and  throat  of  scarlet  fever  appear 
on  the  second  day  all  doubt  is  usually  at  an  end,  but  we  have  to 
remember  that  these  signs  may  both  be  present  in  influenza,  and 
then  the  difficulties  may  be  great.  The  points  to  consider  are 
these,  the  rash  of  influenza  is  not  punctiform,  does  not  begin  on 
the  chest  and  extend  like  scarlet  fever,  is  patchy  in  distribution, 
and  fades  and  intensifies  alternately,  even  from  hour  to  hour. 
Further,  it  is  sometimes  polymorphic,  The  difference  between  an 
influenzal  and  scarlatinal  throat  is  of  great  importance.  The  former 
is  chiefly  pharyngeal,  while  the  latter  chiefly  shows  itself  in  redness, 
enlargement,  and  plugging  of  the  tonsils  and  redness  of  the  soft 
palate.  But  when  it  is  remembered  that  the  tonsils  are  sometimes 
swollen  and  plugged  in  influenza,  it  will  be  seen  how  very  difficult 
it  may  be  to  differentiate  between  the  two  diseases.  The  history  of 
a  previous  attack  diminishes  the  probability  of  scarlet  fever. 

From  measles  the  difficulty  of  diagnosis  arises  during  the  first 
four   days.      The   more  marked  caiarrh  of  the  nose  and  eyes  of 


INFLUENZA  209 

measles  on  the  one  hand,  and  the  definite  pains  of  influenza  on 
the  other,  will  aid  in  the  forming  of  a  judgment.  When  the 
time  for  the  appearance  of  a  measles  rash  arrives,  the  difficulty  is 
usually  at  an  end,  but  it  has  to  be  borne  in  mind  that  a  morbilli- 
form rash  may  accompany  influenza. 

Diphtheria. — In  so  far  as  the  diagnosis  depends  on  the  local  con- 
dition, it  is  the  same  as  that  between  tonsillitis  and  diphtheria.  In 
the  latter  a  cultivation  from  the  throat  will  reveal  the  Loefiler  bacillus. 

Pneumonia. — The  sudden  onset,  the  hot  dry  skin,  are  features 
common  to  the  two  diseases.  But  in  pneumonia,  if  there  is  pain, 
it  is  in  the  side,  not  in  the  head  and  back,  the  breathing  is  rapid, 
and  there  may  be  herpes  of  the  lips.  Further,  signs  of  extensive 
lobar  consolidation — dulness,  marked  tubular  breathing,  increased 
voice  sounds — would  be  convincing  evidence  of  croupous  pneumonia, 
although  the  absence  of  these  signs  must  not  lead  to  a  contrary 
opinion  from  the  fact  that  the  appearance  of  physical  signs  in 
pneumonia  is  often  delayed  several  days.  It  must  be  remembered, 
too,  that  pneumonia  is  an  early  complication  of  influenza.  The 
distinctions  between  influenzal  and  pneumococcal  pneumonia  are 
well  defined.  In  the  latter  the  distribution  is  lobar  and  clearly 
circumscribed  ;  in  the  former  it  is  lobular  and  ill-defined ;  in  the 
latter  there  are  tubular  breathing  and  increased  voice  and  breath 
sounds  over  an  area  of  distinct  dulness ;  in  the  former  there  are 
no  such  signs,  but  diminished  breath  sounds  and  sticky  crepitations 
over  ill-defined  areas,  slightly,  but  not  distinctly,  dull.  An  examina- 
tion of  the  sputum  for  bacillus  influenzae  should  be  made  in  cases 
of  doubt. 

When  a  case  hitherto  thought  to  be  influenza  develops 
shivering,  rigors,  hectic  temperature  and  sweating,  doubts  may 
occur,  and  the  possible  existence  of  deep-seated  suppuration,  of 
pyaemia,  or  of  malaria,  be  thought  of.  But  the  fact  that  influenza 
may  develop  malarial  characters,  and  the  early  history  of  the 
attack,  or  the  absence  of  primary  or  secondary  foci  of  suppuration 
should  lead  to  a  right  judgment. 

Enteric  fever. — This  question  arises  at  two  stages  of  the  illness — 
during  the  first  few  days  when  the  evidences  of  influenza  are  perhaps 
ill-marked,  and  again  when  the  fever  extends  into  the  second  or 
third  week.  In  the  former  case,  doubt  is  felt  at  the  commence- 
ment of  the  iUness,  and  is  usually  set  at  rest  by  the  faU  of  tempera- 
ture and  amelioration  of  the  symptoms  on  the  third  or  fourth  day ; 
while  in  the  latter  case  doubt  develops  later  in  the  physician's 
mind,  and  a  diagnosis  of  influenza  which  he  at  first  adopted  with 

VOL.  I  P 


2  13  MANUAL  OF  MEDICINE 

certainty,  becomes,  as  the  days  roll  by,  more  and  more  open  to 
question.  Since  influenza  and  typhoid  are  both  diseases  whose 
positive  evidences  are  sometimes  lacking,  it  will  be  readily  under- 
stood that  a  confident  diagnosis  may  at  times  be  impossible.  The 
points  of  distinction  to  attend  to  are  these.  The  pain  of  typhoid 
is  chiefly  confined  to  the  head,  while  that  of  influenza  is  as  marked 
in  the  back  and  legs  ;  the  tongue  of  typhoid  during  the  first  week  or 
ten  days  resembles  that  of  influenza,  but,  unlike  influenza,  changes 
to  a  dry,  glazed,  cracked  appearance  towards  the  end  of  the 
second  week ;  in  typhoid,  a  distended  elastic  abdomen  and  a 
palpable  spleen  are  common,  while  in  influenza  they  are  un- 
common. The  presence  of  the  typical  diarrhoea  is  in  favour  of 
typhoid,  but  it  is  important  to  bear  in  mind  that  its  absence  is  not 
evidence  to  the  contrary,  for  constipation  is  as  frequently  met  with 
in  that  disease.  The  same  holds  good  with  regard  to  rose-coloured 
spots — their  appearance  goes  far  to  determine  a  diagnosis  of 
typhoid,  but  their  absence  does  not  point  strongly  to  influenza, 
considering  that  they  may  be  long  delayed,  or  even  absent  alto- 
gether. By  the  middle  of  the  second  week  the  general  condition 
of  a  typhoid  patient,  as  evidenced  by  the  appearance  and  wasting, 
mental  dulness  and  apathy,  is  distinctive,  and  becomes  more 
accentuated  with  the  lapse  of  each  subsequent  day.  On  the  other 
hand,  with  influenza,  unless  aggravated  by  some  grave  complication, 
there  is,  although  great  weakness,  no  such  marked  wasting,  and  the 
patient  continues  to  take  notice  of  his  surroundings.  And,  lastly, 
Widal's  serum  test  should  be  employed,  remembering  that,  though 
evidence  of  importance  which  should  contribute  to  the  forming  of 
a  judgment,  it  is  not  infallible. 

Gastro-enteric  influenza  is  Hable  to  be  confused  with  other 
causes  of  sudden  diarrhoea  and  vomiting,  such  as  poisoning,  either 
ptomaine  or  metallic.  In  poisoning  the  subnormal  or  normal 
temperature,  the  marked  and  early  collapse,  and  the  history  lead 
to  a  right  diagnosis.  But  sudden  pain  and  vomiting  may  be  the 
only  symptoms,  and  then  this  form  of  influenza  has  to  be  distin- 
guished from  other  causes  of  acute  abdominal  pain,  such  as  the 
various  forms  of  colic,  and  even  peritonitis. 

In  many  of  its  features  influenza  resembles  dengue  ;  the  sudden 
onset,  severe  pain  in  head  and  back,  nervous  prostration  and  high 
temperature,  are  alike  in  both.  But  in  the  latter  affection  the 
joint  pains  are  more  constant  and  tend  to  last  longer,  and  a 
roseolar  exanthem  starting  in  the  hands  and  spreading  to  the  trunk, 
followed  by  desquamation,  is  usually  to  be  seen. 


INFLUENZA  ^  2 1 1 

Morbid  anatomy. — Characteristic  changes  are  few,  and  are 
almost  entirely  confined  to  the  pulmonary  type  of  the  disease. 
The  trachea  and  bronchi  are  red,  injected,  and  contain  tenacious 
mucus.  The  lungs  show  the  changes  of  a  broncho-pneumonia ; 
they  are  imperfectly  serated,  and  on  squeezing  them  a  thick  muco- 
pus  exudes  from  the  bronchioles.  Disseminated  patches  of  con- 
solidation of  varying  density  are  seen.  They  are  smooth  and  of 
darker  hue.  and  interspersed  amongst  them  are  areas  of  aerated  and 
collapsed  lung  tissue.  Or  through  coalescence  of  the  lobular  areas 
the  lung  may  present  some  resemblance  to  lobar  pneumonia,  but 
its  section  has  not  the  homogeneous  granulated  appearance  of  that 
condition.  Under  the  microscope  the  changes  seen  are  those  of 
broncho-pneumonia.  There  have  also  been  described  small  areas 
of  purulent  infiltration,  the  centres  of  which  are  packed  with  round 
cells.  Pleurisy  is  sometimes  found  in  conjunction  with  the  above 
changes.  As  in  other  acute  infections,  the  spleen  is  frequently 
somewhat  enlarged  and  soft. 

Etiology. — Influenza  is  a  communicable  disease  propagated 
from  person  to  person.  The  critical  study  by  Dr.  Parsons  of  the 
1 889-1 892  epidemics  pointed  strongly  to  the  conclusion  that  the 
spread  of  the  disease  was  conditioned  by  human  intercourse  and 
was  not  dependent  upon  air-borne  infection.  The  rate,  and  still 
more  the  mode  of  extension  strongly  supported  this  view,  and,  as 
will  be  seen  below,  what  we  know  of  the  bacteriology  of  the  disease 
leads  to  a  like  conclusion.  Several  distinguished  physicians  of  the 
eighteenth  century  taught  that  the  disease  was  contagious,  but  until 
the  investigations  which  sprang  from  our  recent  visitations,  the 
teaching  of  the  nineteenth  century  has  favoured  an  air-borne 
theory  of  infection.  This  view  owed  much  of  its  strength  to  the 
lightning-like  rapidity  with  which  the  disease  struck  down  large 
numbers  of  people  within  a  very  short  space  of  time.  This  feature, 
in  common  with  some  others,  is  the  combined  effect  of  a  short 
incubation  period,  an  early  infectiousness,  a  widespread  suscepti- 
bility and  early  unrecognised  cases.  The  incubation  period  is 
two  to  six  days,  and  perhaps  at  times  the  limits  are  wider.  In- 
fectiousness commences  very  early,  often  within  the  first  twenty- 
four  hours,  and  it  may  be  before  the  character  of  the  disease  has 
declared  itself.  It  persists  as  long  as  the  acute  symptoms,  and  in 
the  pulmonary  form  as  long  as  the  catarrh  lasts,  and,  judging  by  the 
presence  of  Pfeiffer's  bacillus,  even  longer.  The  widespread  sus- 
ceptibility is  due  to  the  very  imperfect  and  transient  immunity  con- 
ferred by  a  previous  attack.     Indeed,  with  some  people  one  attack 


212  , MANUAL  OF  MEDICINE 

predisposes  to,  rather  than  protects  from,  another.  Granting,  for 
the  sake  of  illustration,  an  incubation  period  of  two  days,  a  power 
of  infection  commencing  at  the  end  of  the  first  day's  illness,  and 
that  each  case  each  day  infects  two  or  three  people,  a  simple  calcu- 
lation will  show  that  a  single  case  will  have  become  converted  into 
many  hundreds  after  a  very  short  time. 

Bacteriology. — The  bacillus  infiuenzcB  was  discovered  by  R. 
Pfeiffer  in  1892.  It  occurs  singly  or  in  clumps  as  very  minute 
rods  1.2  /J,  X  0.4  /x,  devoid  of  capsules.  The  bacilli  are  found  abund- 
antly in  the  respiratory  tract,  often  existing  in  pure  culture  in  the 
sputum  either  in  or  among  the  leucocytes.  In  the  nose,  mouth, 
and  pharynx,  they  are  present,  but  admixed  with  other  microbes. 
They  have  been  obtained  from  the  discharge  in  cases  of  otitis 
media,  and  from  five  or  six  cases  of  fatal  meningitis.  In  the  blood 
it  is  the  exception  to  find  them,  and  it  is  probable  that  when  present 
they  do  not  survive  long.     They  are  found  in  no  other  disease. 

To  search  for  the  bacilli  in  the  sputum,  select  for  choice  the  small 
greenish-yellow  masses  in  the  latter,  make  cover-glass  preparations,  dry 
and  stain  for  a  quarter  of  an  hour  in  Ziehl-Neelsen's  carbol  fuchsine 
(i  in  12  of  water),  afterwards  wash,  dry  and  mount  in  Canada  balsam. 
The  poles  of  the  bacilli  stain,  while  the  middle  portions  do  not;  so  that 
at  first  sight  they  show  a  resemblance  to  diplococci  if  isolated,  or  to 
streptococci  if  several  are  placed  end  on. 

Artificial  cultures  are  not  easy  to  make  or  preserve.  The  best 
medium  is  blood  agar,  and,  if  a  streak  cultivation  with  sputum  be  made, 
after  twenty-four  hours  at  the  body  temperature  colonies  will  appear 
consisting  of  minute  transparent  dots  like  drops  of  dew.  These  colonies 
will  not  live  long,  and  if  it  is  desired  to  preserve  the  strain,  subcultures 
have  to  be  made  every  second  day. 

The  vitality  of  the  bacillus  is  low,  its  maximum  temperature  is 
42°  C,  and  its  minimum  is  25°  C,  while  it  thrives  best  at  the  normal 
temperature  of  the  human  body.  It  will  not  live  beyond  two  days, 
either  in  the  dry  state  {e.g.  dried  sputum)  or  in  water,  but  in  moist 
sputum  its  vitality  extends  to  two  or  three  weeks. 

Animals  are  for  the  most  part  immune,  and  numerous  attempts 
to  reproduce  the  disease  in  them  have  yielded  negative  results. 
Although  this  is  a  weak  link  in  the  chain  of  evidence,  there  is 
little  doubt  that  the  bacillus  influenzae  holds  a  causal  relationship 
with  the  disease.  The  bacilli  do  not  circulate  in  the  blood,  but 
find  their  home  in  the  respiratory  tract  and  other  places  congenial 
to  their  growth.      Here  the  toxines  are  produced,  and,  entering  the 


INFLUENZA  213 

circulation,  work  havoc  in  different  tissues,  but  especially  in  nerve- 
cells  and  fibres,  thus  resembling  diphtheria. 

The  mode  of  propagation  of  influenza,  the  low  resisting  power 
of  the  bacilli,  the  small  range  of  temperature  within  which  they 
flourish,  their  inability  to  live  but  a  short  time  in  a  dry  condition 
or  in  water,  and  the  immunity  of  animals,  all  lead  to  the  conclusion 
that  the  disease  is  mainly  spread  from  person  to  person,  either 
directly  or  mediately  by  means  of  fomites.  It  now  can  be  under- 
stood why  it  is  that  such  factors  as  climate,  soil,  altitude,  occupation 
and  sanitary  surroundings  have  little  or  no  bearing  on  the  incidence 
of  the  disease. 

There  are,  however,  many  problems  connected  with  the  spread 
of  influenza  as  yet  unsolved.  Why,  for  instance,  should  the  disease 
spring  up  simultaneously  in  epidemic  form  in  widely  separated 
regions  of  the  earth's  surface?  Thus  the  1891  epidemic  began 
simultaneously  in  the  month  of  March  in  Yorkshire,  Wales,  and  the 
United  States.  Why,  again,  are  the  visitations  intermittent  ?  There 
must  be  external  conditions  of  the  nature  of  which  we  are  ignorant, 
acting  over  wide  areas,  that  either  increase  the  life  activity  and 
virulence  of  the  microbe,  or  the  vulnerability  of  the  human  beings 
exposed  to  its  action. 

Prognosis. — The  severity  of  the  disease  and  therefore  its 
mortality  vary  grea'dy  in  different  epidemics.  At  all  times  a  large 
proportion  of  the  deaths  is  due  either  to  influenzal  broncho- 
pneumonia or  supervening  pulmonary  complications.  With  the 
simpler  forms  of  the  disease,  which  constitute  the  majority  of  the 
cases,  given  previous  good  health  and  eflicient  treatment  recovery 
is  to  be  expected.  Amongst  the  aged  and  those  who  are  weakly 
even  the  milder  forms  of  the  disease  afford  cause  for  anxiety,  and 
recovery,  if  such  results,  is  often  incomplete.  As  regards  the  late 
effects  of  influenza,  although  they  may  linger — it  may  be  for  months 
or  even  years — with  a  most  discouraging  persistence,  yet,  if  there 
is  no  organic  lesion  and  the  patient  was  previously  of  sound  con- 
stitution and  is  not  old,  ultimate  restoration  to  health  is  the  rule. 

Prophylaxis. — It  is  most  important  for  the  fact  to  be  recog- 
nised that  influenza  is  an  infectious  disease  whose  spread  can  be 
checked  by  isolation.  In  institutions  like  workhouses,  whose 
normal  relations  with  the  outside  world  are  restricted,  and  in  which 
strict  isolation  of  first  cases  is  carried  out,  it  is  possible  to  protect 
the  inmates  from  infection  even  when  the  disease  is  raging  in  their 
immediate  neighbourhood.  When,  however,  on  the  one  hand, 
the  peculiar  features  of  the  disease,  and  on  the  other  hand  the 


214  MANUAL  OF  MEDICINE 

conditions  of  social  life  are  considered,  it  must  be  admitted  that 
isolation  has  its  limitations  and  can  only  mitigate  but  not  entirely 
prevent  an  epidemic.  The  question  then  arises — What  measures 
that  are  practicable  can  be  taken  by  a  community  to  check  the 
spread  of  the  disease  ? 

(i)  As  far  as  possible  prevent  the  contact  of  the  uninfected 
with  the  infected.  Thus,  people  who  are  down  with  the  disease 
should  remain  indoors,  not  only  for  their  own  sakes,  but  for  the 
sake  of  others.  It  might  be  desirable  to  close  schools ;  and  large 
assemblages  of  people,  as  in  theatres  and  churches,  should  be 
avoided.  (2)  Good  ventilation  and  cleanliness  of  street,  house, 
and  person  are  important.  (3)  The  sputum  should  be  kept  moist. 
(4)  The  room  and  clothing  of  a  patient  should,  when  practicable, 
be  disinfected  at  the  end  of  the  attack.  In  schools  isolation  should 
be  continued  for  at  least  a  week  after  the  subsidence  of  symptoms. 

Treatment. — The  underlying  aim  of  treatment  should  be  "  to 
help  him  to  bear  it."  There  is  not  only  the  crushing  effect  of  the 
original  onslaught  to  be  dealt  with,  but  it  is  impossible  to  tell  what 
the  duration  of  the  illness  will  be,  or  what  complications  will 
supervene.  What  begins  as  an  apparently  mild,  develops  into  a 
severe  attack,  and  some  complications  are  as  prone  to  follow  mild 
as  severe  invasions.  What  has  to  be  done  is  to  save  the  nervous 
system  the  wear  and  tear — the  devitalising  effects  of  pain  and  distress, 
and  this  may  be  achieved  by  measures  that  make  for  comfort,  and 
therefore  for  strength,  and  measures  that  relieve  discomfort. 

Bed  is  the  only  place  for  the  victims  of  influenza,  and  it  cannot 
be  too  strongly  insisted  that  the  need  for  bed  in  a  mild  case  of 
this  disease  is  as  urgent  as  in  a  mild  case  of  diphtheria.  Many 
fatal  results  have  followed  the  neglect  of  this  precaution. 

Food.—\x\  the  early  stages,  milk  and  meat-fluids  are  all  that  the 
patient  wants,  or  that  it  is  useful  to  give  him.  As  soon  as  the 
more  urgent  symptoms  of  illness  subside,  it  is  well  to  try  and 
cautiously  extend  the  dietary  by  tempting  morsels  of  easily-digested 
food,  such  as  custards,  jellies,  oysters,  white  fish,  boiled  chicken, 
sweetbread.  And  here  it  may  with  advantage  be  mentioned  that  a 
remnant  of  fever  and  a  persistence  of  fur  on  the  tongue  need  not 
be  a  bar  to  solid  food.  Indeed,  their  disappearance  is  often  pro- 
moted by  the  change  from  liquid  diet,  partly  perhaps  because  of 
the  encouragement  the  patient  feels  on  returning  to  a  food  more 
resembling  that  of  health. 

Free  action  of  the  bowels  should  be  secured,  but  severe  purga- 
tion avjjded, 


INFLUENZA  2 1 5 

To  diminish  the  pains. — Phenacetin,  methylacetanilide,  phena- 
zone  and  allied  drugs  are  of  great  use.  The  first  is,  as  a  rule, 
the  best,  and  is  given  in  powder,  gr.  8  to  10  for  an  adult  every 
three  or  four  hours,  according  to  the  severity  of  the  symptoms. 
If  the  circulation  is  depressed,  or  the  patient  weakly,  it  is  well 
to  combine  caffeine  gr.  2  with  each  dose  of  phenacetin.  Methyl- 
acetanilide is  conveniently  administered  in  mixture  —  4  grains 
for  a  dose,  put  up  with  tinct.  aurantii  to  dissolve  and  flavour 
it.  Salicin  and  salicylates  are  sometimes  employed  with  the 
same  objects  as  the  foregoing,  but  in  efficiency  they  are  inferior. 
Sometimes  a  saline  diuretic  and  diaphoretic  mixture  affords  most 
relief. 

In  a  disease  productive  of  so  much  weariness  and  distress,  it  is 
of  the  highest  importance  to  give  the  body  some  rest  and  the  mind 
some  forgetfulness.  Sleep  should  be  secured  by  the  exhibition  of 
hypnotics  alone,  or  in  combination  with  anodynes.  Of  these 
trional  and  sulphonal  are  the  most  suitable ;  they  have  not  the 
depressing  effects  of  chloral  nor  the  persistently  unpleasant  taste  of 
paraldeheyde.  Trional  has  an  advantage  over  sulphonal  in  that  its 
latent  period  is  shorter.  Where  there  is  acute  pain,  a  hypnotic  will 
not  alone  secure  sleep,  but  needs  the  assistance  of  the  anodyne 
effect  of  opium.  A  good  combination  is  10  to  15  grains  of  Dover's 
powder  with  20  grains  of  trional  administered  in  a  cachet.  Or 
the  opium  may  be  given  as  a  morphia  injection  and  the  trional  or 
sulphonal  by  the  mouth.  In  one  acute  form  only  of  influenza 
must  the  use  of  morphia  be  avoided  or  employed  with  great 
caution,  namely,  in  the  broncho  -  pneumonic.  There  the  great 
tenacity  of  the  sputum  and  the  diffuse  distribution  of  the  inflam- 
mation render  its  use  hazardous. 

Stimula?tts. — These  are  not  required  if  the  form  of  the  disease 
is  simple  and  the  subjects  are  robust.  But  if  the  attack  is  pro- 
longed or  of  a  severe  type,  and  if  the  patient  is  either  old  or  of 
weakly  constitution,  alcohol  is  both  necessary  and  desirable.  Where 
there  is  evidence  of  cardiac  and  respiratory  failure  ammonia  and 
ether,  or  better,  perhaps,  hypodermic  injections  of  strychnine  (gr, 
-gij-  to  -^^\  or  caffeine  (gr.  2),  should  be  prescribed  even  to  several 
times  in  the  twenty-four  hours. 

The  dryness  and  soreness  of  the  throat  usually  require  relief ;  an 
inhalation  of  carbolic  acid  partially  secures  this — R  Acidi  carbolici 
liq.  Aq.  aa  5ij.  Misce.  One  drachm  to  the  pint  of  hot  water. 
Inhalations  of  pumiline  and  Tinct.  Benzoin  co  :  may  also  be 
employed.     Carbolic  acid  may  also  be  used  as  a  gargle.     R  Acid 


2i6  MANUAL  OF  MEDICINE 

carbol.  liq.  3i.,  Glycerine  31.,  Inf.  Rosae  acid :  ad  511].  Mix  and 
dilute  with  equal  parts  of  hot  water. 

It  is  a  great  comfort  to  the  patient  to  have  the  furred  tongue 
and  the  mouth  cleaned.  This  is  best  done  by  means  of  cotton  wool 
held  by  dressing  forceps  and  dipped  in  the  following  solution — 
R  Acid  carbolici  liq.  3ss.,  Hydrogen  peroxidi  sij.,  Glycerini  boracis 
31.,  aquam  ad  5vi.  Misce.  Used  as  it  is,  or  diluted  with  a  little 
warm  water.  This  preparation  may  also  be  used  as  a  gargle  or 
spray. 

Where  the  pahis  in,  or  more  often  round,  the  joints  are  severe 
and  persistent,  relief  may  be  given  by  glycerine  of  belladonna  and 
moist  heat  locally. 

Influenzal  broncho-pneumonia  is  exceedingly  resistant  to  treat- 
ment. Its  irritable  cough  and  its  sticky  sputum  often  seem  but 
little  affected  by  such  expectorant  remedies  as  ipecacuanha,  potassium 
iodide,  ammonia,  squills,  etc.  Turpentine,  5  to  10  minims  for  a 
dose,  in  gelatine  capsules  every  four  hours,  sometimes  does  good, 
but  when  giving  this  drug  the  urine  must  be  carefully  watched. 
The  necessity  for  caution  in  the  use  of  opium  in  this  condition  has 
already  been  referred  to.  External  applications  in  the  shape  of 
poultices  not  only  afford  comfort  but  help  to  loosen  the  sputum. 

For  the  gastro-intestinal  symptoms  nourishment  should  be  restricted 
to  milk,  with  soda  or  barley  water  given  in  small  quantities  frequently. 
If  there  is  vomiting  a  blister  to  the  epigastrium  will  often  stop  it, 
and  hot  applications  will  allay  abdominal  pain.  For  drugs,  sodium 
bicarbonate,  sal  volatile,  and  spirits  of  chloroform,  with  t?ie  addition 
of  morphia  to  check  the  pain  and  diarrhoea.  If  vomiting  is  a 
persistent  feature  acid  hydrocyanic:  dil:  or  the  agreeable  tinctura 
pruni  Virginians,  may  be  added  to  the  above.  Bismuth  is  also 
employed,  but  is  of  less  use  than  in  simple  gastro-intestinal 
irritation. 

The  malarial  type  yields  well  to  quinine  given  in  3  to  5  grain 
doses  three  or  four  times  daily. 

During  convalescefice  the  patient  should  not  be  allowed  to  get  up 
till  the  temperature  has  been  down  for  some  days,  and  then  only 
with  caution,  always  bearing  in  mind  the  liability  to  relapse.  The 
diet  should  be  generous  and  the  appetite  encouraged,  and  a  little 
wine  with  the  food  should  be  allowed.  Quinine  is  now  the  drug 
most  generally  useful,  alone  or  in  combination  with  strychnine.  As 
recovery  is  approached  iron  should  be  added.  Where  possible  a 
change  of  air  should  always  be  advised,  and  after  severe  attacks 
should   be   strongly  insisted   upon.      It   is   only   in  this   way  that 


GLANDERS  217 

recovery  is  consolidated  and  the  long  and  varying  train  of  sequelae 
avoided.  The  treatments  of  the  late  effects  of  the  disease  do  not 
call  for  detailed  description.  A  word  of  warning,  however,  is 
needed  concerning  the  insomnia,  the  various  neuralgias  and  distress- 
ful feelings  that  sometimes  tarry  so  long  and  wearily.  On  no 
account  must  opium  be  employed  for  their  relief.  This  drug  is  as 
bad  at  this  stage  as  it  is  often  good  in  the  first  and  acute  stage. 
Hypnotics,  too,  like  trional  and  sulphonal,  must  be  given  cautiously. 

Bertrand  Dawson. 


GLANDERS 

Syn.  Farcy,  Equinia,  Malleus 

An  infectious  disorder  peculiar  to  the  horse  and  ass,  though 
transmissible  to  other  animals,  and  also  to  man. 

In  the  majority  of  cases  of  human  glanders  the  patient  acquires 
the  disorder  directly,  by  inoculating  a  sore  or  wound  of  the  skin  or 
mucous  membrane.  In  other  instances  the  contagium  seems  to 
gain  entrance  through  the  respiratory  mucosa,  the  tonsils,  or  the 
alimentary  canal. 

Nearly  all  the  recorded  cases  have  occurred  in  males,  and  in 
those  who  are  closely  associated  with  horses,  such  as  stablemen, 
grooms,  knackers,  etc.  ;  but  occasionally  the  infection  has  been 
transferred  from  man  to  man,  and  the  malady  has  been  acquired  in 
the  laboratory. 

Bacteriology. — The  actual  exciting  cause  is  a  schizomycete, 
bacillus  mallei,  a  microbe  about  the  same  size  as,  but  rather  thicker 
than  the  tubercle  bacillus.  Though  an  aerobe,  B.  mallei  is  also  a 
potential  auccrobe.  Its  cultural  appearances  in  glycerin-agar  and 
blood-serum  are  sufficiently  distinctive,  but  on  potato  the  growth  is 
quite  characteristic.  On  this  medium  at  incubation  temperature  the 
growth  is  at  first  honey  or  amber  yellow  in  hue,  afterwards  darken- 
ing to  brown.  The  microbe  is  best  stained  with  phenol-fuchsin  or 
with  phenol-methylene  blue.  It  does  not  stain  by  Gram's  method. 
From  veal  broth  cultures,  its  specific  metabolic  product,  mallein,  is 
obtained  by  filtration.  This  is  used  for  diagnostic  purposes,  and 
when  injected  into  glandered  animals  it  excites  a  marked  local  and 


2i8  MANUAL  OF  MEDICIXE 

general  reaction.  Another  experimental  test  is  afforded  by  injecting 
pure  cultures  into  guinea-pigs,  whereby  a  glanderous  caseation  of 
the  testicles  is  almost  invariably  determined. 

The  average  incubation  period  is  from  three  to  five  days,  but  it 
may  be  shorter,  and  incubations  of  fifteen  to  twenty  days  are  known. 

Symptoms. — ^The  onset  of  the  disease  is  usually  marked  by  a 
rigor  or  frequent  shiverings,  malaise,  headache,  pyrexia,  hot,  dry 
skin,  by  general  pains,  especially  marked  in  the  joints  and  muscles, 
and  by  prostration. 

The  febrile  symptoms  are  followed  by  an  eruption  which  rapidly 
appears  when  the  infection  is  the  result  of  direct  inoculation,  but 
may  be  delayed  when  there  is  no  definite  local  origin.  The  inocu- 
lation site  swells,  pustules  form,  and  thereafter,  breaking  down,  dis- 
charge a  foetid  ichorous  pus.  Swellings  which  rapidly  suppurate 
may  appear  in  other  parts  of  the  body,  chiefly  on  the  skin,  muscles, 
mucosa  of  the  nose,  and  in  the  lymphatics  and  lymphatic  glands. 
In  many  cases  there  is  a  specific  pneumonia,  a  purulent  arthritis, 
and  in  very  severe  cases  an  erysipelatoid  tumefaction  of  the  face. 
Such  acute  cases  last  for  about  a  fortnight.  Chronic  cases  continue 
for  weeks,  and  may  drag  on  for  months.  In  these  the  febrile 
phenomena  are  less  severe,  and  the  anatomical  lesions  less  frequent 
and  often  indolent.  Yet  these  chronic  cases  may  terminate  in  acute 
glanders. 

The  clinical  pictures  presented  by  glanders  vary  much  as  to 
the  duration  of  the  disease  and  the  extent  and  distribution  of  the 
anatomical  lesions.  For  descriptive  purposes  the  disease  has  been 
subdivided  into  acute  and  chronic  glanders,  and  acute  and  chronic 
farcy.  The  distinction  made  between  glanders  and  farcy  refers  to 
the  greater  extent  to  which  the  respiratory  system  is  affected  in  the 
former  and  the  prominent  position  taken  by  the  skin  in  the  latter, 
the  so-ca.lled  farcy  buds  being  nothing  more  than  either  the  swollen 
lymphatic  glands  or  the  morbid  collections  in  the  cutaneous  lymph- 
atic vessels.  A  perusal  of  recorded  cases  will,  however,  show  that 
no  distinct  line  can  be  drawn  between  the  two  even  clinically,  and 
will  convey  the  notion  that  glanders  is  a  specific  disorder  on  pyjemic 
lines,  characterised  by  more  or  less  febrile  phenomena  and  by 
caseating,  suppurating  or  ulcerative  lesions  in  skin,  mucous  mem- 
brane, muscles,  lungs,  etc. 

In  many  instances  the  naso-phar}'ngeal  mucosa  is  little  if  at  all 
implicated.  But  should  the  mucosa  of  the  nasal  passages  be  affected 
by  continuity  or  by  metastasis,  a  discharge,  at  first  mucoid,  rapidly 
becoming  purulent  or  saniopurulent,  flows  from  the  anterior   and 


GLANDERS  219 

posterior  nares.  This  glanderous  ozaena  may  infect  the  lungs  and 
alimentary  canal.  The  inflammation  of  the  lungs  is  indicated  by 
dyspnoea  and  by  saniopurulent  expectoration,  the  physical  signs  of 
pulmonary  consolidation  beiiig  frequently  absent.  Infection  of  the 
intestine  is  indicated  by  diarrhcea  and  offensive  stools. 

In  chronic  cases  the  original  infection  site  may  present  the 
aspect  of  an  intractable  chronic  ulcer  from  which  proceed  the 
thickened  lymphatics  and  their  swollen  glands.  In  the  majority  of 
the  recorded  cases  the  virus  has  been  inoculated  on  a  sore  or  wound, 
but  there  are  many  instances  where  no  such  local  infection  has  been 
demonstrable.  In  these  the  incubation  period  seems  to  have  been 
longer,  and  after  the  general  febrile  symptoms  have  declared  them- 
selves the  disease  has  become  diagnosable  by  the  advent  of  a 
vesicular  eruption  rapidly  suppurating,  by  the  occurrence  of  intra- 
muscular abscesses,  by  a  foetid  ozaena,  or  by  the  specific  pneumonitis. 

The  character  of  the  pyrexia  is  variable ;  it  may  be  continuous 
or  of  the  remittent  type  ;  it  may  be  slight  or  severe  (104°  or  higher). 

A  positive  diagnosis  of  glanders  is  at  first  often  difficult. 
Considerable  assistance  will,  of  course,  be  received  from  a  know- 
ledge of  the  patient's  occupation  and  a  possibility  of  contact  with 
the  virus.  In  chronic  cases  one  of  the  most  prominent  features  is 
old-standing  ulcerations  of  the  skin,  and  such  sores  have  more  than 
once  been  mistaken  for  those  of  tertiary  syphihs.  The  induration 
and  thickening  of  the  lymphatic  glands  and  vessels  in  connection 
with  the  sore  may  help  to  guard  against  this  error. 

When  the  disease  is  suspected  a  diagnosis  may  be  made  by 
bacterioscopic  examination  of  the  contents  of  the  pustules,  of  the 
abscesses  or  of  the  discharges  ;  by  the  characteristic  cultural  ap- 
pearances of  the  bacillus,  especially  on  potato ;  by  inoculation  of 
the  peritoneal  sac  of  guinea-pigs  with  pure  cultures ;  by  means  of 
the  serum  test  or  by  the  reaction  to  mallein  which  consists  of  the 
chemical  products  derived  from  the  artificial  culture  of  the  bacillus 
mallei,  subcutaneous  injection  of  which  causes  a  reaction  similar  to 
that  produced  by  tuberculin  in  persons  suffering  from  tuberculosis. 

The  prognosis  is  always  bad.  Nearly  all  the  acute  cases  are 
fatal,  and  of  the  chronic  ones  many  terminate  as  acute  glanders. 

Of  the  chronic  cases  about  50  per  cent  are  stated  to  recover, 
and  the  issue  is  the  more  favourable  according  as  the  symptoms  are 
slow  and  indolent  and  the  course  of  the  malady  protracted.  Yet 
when  they  do  recover  a  permanent  condition  of  debility,  general  or 
local,  may  remain. 

The  general  treatment  of  glanders  resolves  itself  into  maintain- 


2  20  MANUAL  OF  MEDICINE 

ing  the  strength  of  the  patient  by  means  of  suitable  and  nourishing 
diet  and  by  stimulants.  Drugs  are  of  little  avail.  Mercury  has 
been  exhibited  both  internally  and  by  inunction,  but  quinine  and 
iron  have  more  repute. 

The  most  effective  part  of  the  treatment  of  glanders  is  surgical 
and  antiseptic.  The  pustules,  sores,  and  abscesses  should  receive 
constant  and  energetic  attention,  the  results  being  the  more  satisfac- 
tory according  as  the  cases  are  less  acute  and  more  chronic. 

It  is  hardly  necessary  to  point  out  that  the  dressings,  soiled 
clothes,  etc.,  should  be  carefully  disinfected,  or,  what  is  better, 
burned. 

R.  G.  Hebb. 


TUBERCULOSIS 

Tuberculosis  is  a  specific  infective  disease  set  up  by  the  action  of 
a  special  virus,  this  last  being  a  micro-organism  now  well  recognised 
and  distinguished  as  the  tubercle  bacillus.  This  bacillus,  either 
directly,  or  by  means  of  chemical  products  due  to  its  presence,  causes 
a  special  form  of  inflammation  of  the  tissues,  resulting  in  the  forma- 
tion of  what  is  known  as  acute  miliary  tubercle  or  tuberculous 
nodules. 

The  present  article  deals  with  tuberculosis  generally,  its  modes 
of  invasion,  its  methods  of  local  increase  and  extension  to  other 
organs,  and  its  distribution  throughout  the  body.  For  its  effects 
upon  the  separate  organs,  and  the  symptoms  resulting  from  them, 
reference  must  be  made  to  the  articles  dealing  with  the  diseases 
special  to  those  organs. 

Bacteriology. — The  tubercle  hacillus  can  be  readily  demon- 
strated in  the  sputa  of  tuberculous  subjects,  and  is  commonly  found 
in  the  urine,  pus,  and  other  secretions  from  parts  affected  with  the 
disease.  It  can  also  be  shown  in  sections  cut  from  the  affected 
tissues.  The  bacillus  is  a  motionless  rod  with  rounded  ends,  about 
one-half  the  diameter  of  a  blood  corpuscle  in  length,  and  about  one- 
sixth  of  its  own  length  in  thickness  (Plate  II.).  The  bacillus  is  chiefly 
recognised  from  its  behaviour  with  certain  aniline  dyes.  When  a  pre- 
paration containing  it  is  stained  with  carbol-fuchsine  and  afterwards 
treated  with  dilute  mineral  acids,  these  last  remove  the  colouring 
matter  from  all  but  the  bacilli  themselves,  which  then  sometimes 
show  a  beaded   structure  with   alternate  coloured  and  uncoloured 


TUBERCULOSIS  221 

portions.  Whether  this  beading  is  due  to  spore  formation  or  not 
is  as  yet  undetermined.  The  leprosy  bacillus  is  the  only  other 
pathogenetic  organism  at  present  known  with  a  similar  property  of 
retaining  its  colour  when  treated  in  this  way.  (The  caseous  secre- 
tions of  the  glands  of  the  vulva  and  glans  penis  frequently  contain 
a  bacillus  which  closely  corresponds  to  the  organism  of  tubercle 
and  leprosy  in  its  behaviour  to  carbol-fuchsine  and  acids,  though  it 
is  stated  that  alcohol  discharges  the  stain  sooner  in  the  former. 
This  fact  should  be  remembered  when  examining  urine  for  the 
tubercle  bacillus.)  The  ordinary  method  of  showing  the  presence 
of  the  tubercle  bacillus  is  to  first  stain  the  suspected  preparation 
with  carbol-fuchsine,  then  to  decolorise  with  a  dilute  mineral  acid, 
and  finally  to  stain  again  with  methylene  blue,  when  the  bacilli 
retain  the  red  colour  of  the  fuchsine  and  contrast  strongly  with  the 
blue  of  the  rest  of  the  preparation.  The  bacilli  can  be  cultivated 
on  several  special  media  at  temperatures  between  98.5°  F.  and 
102°  F.,  but  in  every  case  the  growth  is  essentially  a  slow  one. 
Except  when  grown  in  this  way,  the  bacilli  have  no  power  of  extra- 
corporeal increase.  They  can,  however,  even  when  dried  up,  retain 
their  vitality  for  a  long  period  of  time. 

Histology. — In  whatever  way  the  virus  may  have  gained  an 
entrance,  the  initial  lesion  is  a  miliary  tubercle,  and  the  successive 
formation  of  such  miliary  tubercles  is  the  essential  and  constant 
feature  of  the  complaint.  Under  the  microscope  this  tubercle  is 
found  to  be  made  up  of  three  separate  zones  or  layers.  The  inner- 
most zone  consists  of  one  or  more  large  many-nucleated  cells,  with 
prominent  branching  processes — the  so-called  giant  cells.  Surround- 
ing the  inner  zone  is  a  layer  of  epithelioid  cells.  Outermost  of  all 
is  a  layer  of  smaller  lymphoid  cells.  These  three  layers  of  cells  are 
not  always  present,  and  a  tubercle  may  be  composed  of  two  only  of 
them,  or  even  of  lymphoid  cells  alone. 

A  single  tubercle  proper,  such  as  that  just  described,  is  hardly 
perceptible  by  the  naked  eye.  Commonly,  however,  several  of  them 
are  aggregated  together,  and  it  is  such  collections  of  them  that  give 
the  characteristic  visible  features  of  the  complaint,  and  to  which  the 
term  tubercle  is  ordinarily  applied.  Before  undergoing  any  retro- 
gressive change,  these  collections  of  tubercles  tend  to  form  little 
tumours  of  a  definite  size,  this  size  varying  somewhat  in  the  different 
tissues  of  the  body ;  and  it  will  be  convenient  to  follow  the  usual 
custom  and  speak  of  such  collections  as  tubercles  simply.  A  tubercle, 
in  this  sense,  is  usually  a  small  globular  body,  about  one-twelfth  of 
an  inch  in  diameter,  pearly  gray  or  yellowish  in  colour,  and  some- 


222  MANUAL  OF  MEDICINE 

what  translucent  in  appearance  (gray  granulation).  It  is  strictly 
extra-vascular,  and  capillaries  can  be  traced  up  to  its  very  margin, 
but  never  into  its  substance.  Sooner  or  later  the  presence  of 
tubercles  is  accompanied  by  inflammation  of  the  tissues  containing 
them,  both  in  their  immediate  neighbourhood  and  in  distant  parts. 

After  reaching  maturity,  tubercles  are  liable  to  two  forms  of 
degenerative  change — the  caseous  and  the  fibrous.  Both  processes 
are  usually  combined  to  some  extent,  although  the  amount  of  the  one 
generally  predominates  over  the  other. 

(a)  Caseous  degeneration  is  a  form  of  dry  necrosis  which,  owing 
probably  to  its  non-vascularity,  starts  primarily  in  the  tubercle  itself, 
but  afterwards  involves  the  surrounding  inflammatory  products  as 
well.  The  resulting  formation  is  a  homogeneous  yellowish  mass, 
somewhat  of  the  consistence  and  appearance  of  soft  cheese,  which 
was  formerly  known  as  "yellow  tubercle."  Under  the  microscope 
the  degenerated  mass  is  found  to  consist  of  shrivelled  corpuscles 
intermixed  with  granular  debris  and  fat.  By  the  coalescence  of  the 
separate  tubercles  caseous  masses  of  considerable  size  may  be  formed, 
more  especially  in  situations  having  no  connection  with  the  free 
surfaces  of  the  body.  In  active  cases  the  caseous  masses  may  be 
surrounded  by  recent  miliary  tubercles.  Further  changes  may  bring 
about  the  softening  of  the  caseous  material  with  the  formation  of  an 
ulcer  or  an  abscess,  according  as  the  tubercle  occurs  on  a  free  sur- 
face or  in  a  closed  cavity.  When  the  caseous  masses  do  not  soften, 
and  remain  obsolescent,  they  are  apt  to  take  up  lime  salts  from  the 
blood,  and  so  become  transformed  into  cretaceous  material. 

(V)  The  other  form  of  tuberculous  degeneration,  the  fibroid,  is  a 
frequent  feature  in  tuberculosis  of  the  pleura  and  peritoneum,  and 
not  very  uncommon  in  the  lungs.  Here  the  inflammatory  products 
surrounding  the  tubercles,  instead  of  undergoing  caseous  degenera- 
tion, are  transformed  into  fibrous  tissue,  which  is  often  of  con- 
siderable thickness  and  extent.  The  fibroid  change  is  in  the 
direction  of  the  cure  of  the  complaint,  for  the  fibrous  tissue  resulting 
from  it  may  interpose  an  effective  barrier  against  the  spread  of  the 
virus.  In  such  a  change  the  actual  tubercles  themselves  generally 
persist  as  fibrous  nodules,  or  as  small  cretaceous  masses. 

Tuberculosis  in  its  clinical  aspects  presents  itself  in  two  forms  : 
a  chronic  one,  in  which  the  complaint  is  mainly  confined  to  one 
or  two  organs  or  set  of  tissues,  spreading  mainly  by  direct  extension 
or  by  means  of  the  lymphatics ;  and  a  more  or  less  acute  one, 
general  tuberculosis,  in  which  many  organs  are  simultaneously 
attacked  j    in  this  variety  it  is  evident  that  the  virus  must  have 


TUBERCULOSIS  223 

been  carried  by  means  of  the  general  blood  stream.  It  is  this 
generalised  form  which  is  most  frequent  in  infancy  and  early  child- 
hood. 

Invasion  and  distribution. — Of  the  modes  of  entrance  of 
the  bacilli  into  the  human  body  only  three  need  be  considered — 
inoculation  through  a  breach  of  the  skin,  inhalation  through  the  air 
passages,  and  introduction  into  the  alimentary  canal  along  with 
food. 

The  first  mode,  moculatiofi  through  a  breach  of  the  skin,  is 
extremely  rare  :  examples  of  it  being  the  occasional  occurrence  of 
warts  on  the  hands  of  those  making  post-mortem  examinations  on 
tuberculous  subjects. 

The  second  mode,  through  the  agency  of  the  air  passages,  is  by 
far  the  most  frequent  one  by  which  the  disease  is  contracted.  It  is 
by  means  of  the  virus  inspired  with  the  air,  and,  but  less  frequently, 
through  the  agency  of  food,  that  the  glands  in  the  neck,  the  lungs, 
and  the  bronchial  glands  are  usually  infected,  and  it  is  in  few  cases 
of  tuberculosis  that  one  or  more  of  these  structures  is  not  involved. 

The  glands  in  the  neck  are  infected  by  the  bacilli  gaining  en- 
trance to  them  from  the  parts  about  the  mouth,  more  especially 
the  lymphoid  tissue  of  the  tonsils,  and  the  pharynx.  That  the 
organisms  can  gain  an  entrance  to  the  glands  when  the  parts 
inside  the  mouth  are  in  a  healthy  state  is  perhaps  true,  but  that 
an  inflammatory  condition  of  such  parts  assists  their  entrance  is 
more  than  probable.  Once  in  the  glands  the  bacilli  may  multiply 
with  the  resulting  formation  of  miliary  tubercles,  followed  in  due 
course  by  inflammation,  necrosis,  and  caseation.  Such  is  the  origin 
of  the  familiar  and  well-known  "  strumous  "  or  "  scrofulous  "'  glands 
in  the  neck.  (Since  it  is  now  proved  that  the  condition  expressed 
by  these  terms  is  due  to  the  tubercle  bacillus,  their  retention  is  only 
justifiable  on  the  ground  of  clinical  expediency  and  not  on  that  of 
pathological  distinction.)  Here  the  process  may  stop,  and  the 
tuberculous  glands  may  persist  for  many  years  as  chronic  indolent 
swellings.  Often  the  inflammation  goes  beyond  this  point,  and  a 
tuberculous  abscess  forms  in  the  neck.  In  other  cases  the  necrotic 
process  in  the  glands  involves  the  walls  of  the  blood  vessels, 
generally  a  small  vein,  with  the  result  that  the  bacilli  gain  an 
entrance  into  the  general  blood  stream.  Once  m  the  veins  the 
bacilli  are  carried  along  by  the  venous  current  towards  the  lungs, 
and  either  find  a  lodgment  in  the  pulmonary  tissues  or  pass  through 
the  capillaries  of  the  lungs  to  infect  distant  organs.  It  may  be 
remarked   here  that   it  is  almost  certain  that  the  bacilli,  whilst   in 


2  24  MANUAL  OF  MEDICINE 

motion  with  the  blood  stream,  have  no  power  of  multiplying,  and 
only  in  rare  instances  have  they  been  discovered  in  the  blood  itself. 
For  their  increase  a  condition  of  rest  is  probably  an  essential. 
Another  consequence  of  tuberculosis  of  the  glands  is  that  the  in- 
flammatory process  sometimes  leads  to  rupture  of  their  capsules, 
wkh  the  result  that  the  bacilli  gain  an  entrance  into  the  lymph 
current  and  thus  infect  other  glands,  or  pass  into  the  general  blood 
stream  by  way  of  the  thoracic  duct.  Amongst  these  other  glands 
those  at  the  root  of  the  neck  surrounding  the  apices  of  the  lungs, 
and  the  tracheo-bronchial  glands,  are  of  prime  importance,  as  their 
infection  may  lead  by  direct  extension  to  disease  of  the  lungs 
themselves. 

From  the  pharynx  the  bacilli  may  gain  an  entrance  into  the 
tympanicm  by  way  of  the  Eustachian  tube,  and  tuberculous  disease 
of  the  ear  is  frequent  in  children  and  especially  in  infants.  The 
usual  result  of  the  presence  of  the  organisms  is  suppuration  in  the 
tympanic  cavity,  which  may  be  followed  by  caries  or  necrosis  of 
the  petrous  portion  of  the  temporal  bone  and  tuberculosis  of  the 
brain  or  its  membranes.  Much  more  rarely  tuberculous  meningitis 
is  due  to  disease  of  the  bones  at  the  base  of  the  skull ;  the  bacilli 
having  reached  them  by  the  route  of  the  nasal  passages. 

In  the  bmgs  the  bacilli  gain  an  entrance  with  the  inspired  air, 
and  their  first  effects  are  exercised  upon  the  finest  bronchial  tubes. 
The  apices  of  the  lungs  are  the  parts  most  often  attacked,  owing 
doubtless  to  the  fact  that  they  are  the  least  expansile  portions,  and 
that  the  bacilli  are  most  likely  to  attain  a  footing  where  the  air  is 
more  or  less  stagnant.  From  primary  foci  in  the  finer  bronchial 
tubes  the  disease  has  a  tendency  to  spread  in  one  of  two  directions, 
or  in  both  simultaneously,  viz.  along  the  bronchi  to  the  alveoli  of 
the  lungs,  or  else  from  the  bronchi  into  the  surrounding  tissue  and 
thence  by  direct  continuity  into  the  general  connective  tissue  of  the 
organ.  In  both  cases  there  is  progressive  formation  of  tubercles 
and  inflammation  corresponding  to  the  nature  of  the  structures  in- 
vaded. Besides  spreading  by  direct  extension  in  these  directions, 
the  complaint  may  attack  more  distant  parts  through  the  agency  of 
the  blood  vessels  and  lymphatics.  By  the  implication  of  the  walls 
of  the  former,  the  bacilli  may  enter  the  blood  stream,  and  develop 
fresh  miliary  tubercles  in  the  general  connective  tissue  of  the  lungs, 
corresponding  closely  to  the  ramifications  of  the  terminal  branches 
of  the  pulmonary  artery.  Fresh  foci  of  infection,  too,  can  often 
be  traced  in  the  lung  tissue  along  the  course  of  the  lymphatic 
vessels  on  their  way  to  the  bronchial  glands.     These  last  are  invari- 


TUBERCULOSIS  §25 

ably  affected  as  well  as  the  lungs,  and  it  is  only  in  exceptional 
instances  that  any  tuberculous  disease  of  these  glands  is  not  accom- 
panied by  demonstrable  affection  of  the  lungs  as  well.  The  effect 
of  the  disease  in  the  bronchial  glands  is  the  same  as  in  that  of 
the  glands  of  the  neck,  and  the  affection  of  the  bronchial  glands 
may  be  the  means  of  spreading  the  disease  to  the  lungs  or  to  more 
distant  parts,  either  directly  by  means  of  the  blood  vessels,  or  in- 
directly by  the  route  of  the  thoracic  duct.  In  exceptional  instances, 
too,  an  affected  gland  may  ulcerate  into  a  bronchus,  and  the  released 
bacilli  may  set  up  fresh  foci  of  the  complaint  in  many  parts  of  the 
lung  corresponding  to  the  terminations  of  the  finer  bronchi.  In 
other  cases  the  disease  spreads  to  the  pulmonary  tissues  from  the 
glands  surrounding  the  bronchi  in  their  passage  to  the  lungs,  and 
some  authorities  state  that  this  mode  of  infection  of  the  lungs  is 
the  commonest  one  in  infants  and  young  children. 

The  pleura  interposes  a  barrier,  more  or  less  effective,  against 
the  spread  of  the  disease  into  its  cavity,  and  there  may  be  extensive 
disease  of  the  lungs  with  entire  freedom  of  the  pleura.  As  there 
is  in  fact  no  direct  communication  between  the  lymphatics  of  the 
pleura  and  those  of  the  lungs,  the  pleura  can  only  be  infected  by  a 
breach  of  its  surface  through  necrosis  or  other  means.  A  secondary, 
non-tuberculous,  pleurisy  usually,  however,  complicates  pulmonary 
tuberculosis  of  any  great  extent.  In  general  tuberculosis  gray 
miliary  tubercles  are  frequently  found  on  both  the  visceral  and 
parietal  pleural  surfaces.  Not  infrequently,  too,  the  first  clinical 
manifestations  of  tuberculosis  are  exhibited  in  the  pleurae.  It  is 
now  almost  universally  admitted  that  simple,  primary,  serous 
pleurisies  are  generally  tuberculous  in  origin.  However  rapidly 
and  apparently  completely  the  victims  of  such  pleurisies  recover, 
statistics  prove  that  the  majority  of  them  die  before  three  years  are 
over  with  undoubted  tuberculous  disease  of  the  lungs  and  other 
organs. 

Tuberculosis  of  the  pericardiutn  is  seldom  found  except  as  the 
result  of  the  general  disease  when  many  organs  are  involved. 

Tuberculous  disease  of  the  larynx  is  nearly  always  secondary  to 
disease  of  the  lungs,  and  is  probably  due  to  infected  sputa  becoming 
lodged  in  the  folds  of  the  larynx. 

In  the  third  mode  of  entrance  into  the  body,  by  way  of  the 
alimentary  canal,  the  bacilli  can  readily  reach  the  stomach  and  in- 
testines by  being  swallowed  with  the  saliva  or  sputum,  or  by  the  use 
of  infected  food.  Modern  research  has  proved  beyond  question 
the  extreme  frequency  of  the  presence  of  the  bacilli  in  ordinary 
VOT.  I  n 


2  26  MANUAL  OF  MEDICINE 

household  milk  and  butcher's  meat.  It  might  be  expected,  then, 
from  this  fact  that  primary  tuberculosis  of  the  stomach  and  intes- 
tines would  be  of  frequent  occurrence.  Fortunately  this  is  far 
from  the  case,  and  primary  tuberculosis  of  the  intestinal  mucous 
membrane  is  a  rare  event.  Too  much  stress,  then,  has  possibly 
been  laid  upon  the  frequency  of  infection  through  the  agency  of 
food  by  some  recent  authorities  in  their  laudable  attempts  at  con- 
trolling the  disease.  There  can  be  no  doubt,  too,  that  cases  of 
tabes  mesenterica,  i.e.  tuberculosis  of  the  mesenteric  glands,  are 
vastly  exaggerated  in  frequency  in  the  death  returns.  The  com- 
parative freedom  of  the  intestinal  tract  from  infection  due  to  food  is 
no  doubt  due  to  some  destructive  action  of  the  gastric  and  intestinal 
secretions  on  the  bacilli.  Rare  as  a  primary  disease,  tuberculosis  of 
the  intestines  is  far  from  uncommon  as  secondary  to  tuberculosis 
of  other  parts,  most  frequently  that  of  the  lungs.  There  is  every 
reason  for  believing  that  in  this  case  infection  is  incurred  by  the 
swallowing  of  tuberculous  sputa.  It  is  possible  that  in  this  instance 
the  bacilli  are  protected  from  the  destructive  influence  of  the  gastric 
and  intestinal  secretions  by  the  mucus  in  which  they  are  imbedded. 
Tuberculosis  of  the  stomach  is  rare,  although  not  quite  so  un- 
common as  some  authorities  have  asserted.  In  every  case  it  is 
accompanied  by  tuberculosis  of  the  intestines.  The  parts  of  the 
bowels  most  frequently  affected  are  the  lower  end  of  the  ileum 
and  the  large  intestine.  In  the  ileum  the  disease  begins  in  the 
Peyer's  patches  and  the  solitary  glands.  Gray  miliary  tubercles 
form  in  the  lymph  follicles,  and  these  turn  yellow  and  soften 
from  necrotic  change.  The  mucous  membrane  over  and  ad- 
jacent to  the  follicles  sloughs,  and  thus  an  ulcer  is  formed  which 
enlarges  by  the  additional  formation  of  fresh  tubercles  round  its 
margins  and  on  its  base.  The  ulcers  thus  spread  beyond  the  areas 
of  the  Peyer's  patches,  generally  in  the  direction  of  the  blood 
vessels,  and  may  extend  around  the  whole  circumference  of  the 
bowel.  By  the  progressive  destruction  of  the  deeper  parts,  nothing 
of  the  bowel  structure  may  be  left  beyond  the  peritoneal  coat  and 
perforation  may  result,  but  more  often  inflammatory  adhesions  are 
formed  with  neighbouring  coils  of  intestines.  Tuberculous  ulcers 
of  the  ileum  are  not  unfrequently  somewhat  like  in  appearance  to 
typhoid  lesions  in  the  same  situations.  They  are  to  be  distin- 
guished from  these  last  by  their  more  irregular  shape,  their  tendency 
to  spread  across  the  bowel,  the  hardness  of  their  base,  and  from 
the  fact  that  very  often  separate  tubercles  can  be  discerned  in  them 
and  on  the  peritoneal  surface. 


TUBERCULOSIS  227 

Similar  ulcerations,  commencing  in  the  solitary  glands,  also  occur 
in  the  lar^e  i?itcstine.  They  form  rather  deep,  excavated  ulcers,  often 
with  a  small  circular  opening  on  the  mucous  surface  of  the  bowel. 

The  corresponding  Mesenteric  glands  are  invariably  affected 
along  with  the  intestines.  In  some  instances  these  glands  are 
found  in  a  state  of  caseation  where  there  are  no  discoverable  signs 
of  any  present  or  previous  affection  of  the  intestines.  It  is  said 
that  the  disease  may  spread  by  means  of  the  lymphatics  from  the 
mesenteric  glands  to  those  at  the  root  of  the  lungs,  and  that  thus 
the  latter  organs  may  be  infected  from  a  source  arising  from  tuber- 
culous food. 

With  regard  to  the  primary  infection  of  the  glands  of  the  neck, 
of  the  ears,  the  lungs,  and  the  intestines,  there  is  no  difficulty  in 
surmising  as  to  the  mode  of  access  of  the  bacilli  from  the  outside. 
Very  often,  however,  tubercles,  seemingly  primary  in  character,  are 
found  in  parts  of  the  body  remote  from  those  last  named.  It 
may  then  be  far  from  an  easy  matter  to  settle  as  to  the  manner  of 
entrance  of  the  organism  into  the  body.  In  the  vast  majority  of 
such  cases  careful  search  generally  reveals  an  older  focus  of  in- 
fection, most  often  a  caseous  gland.  In  rare  instances  no  such 
source  of  infection  is  found,  and  in  such  the  affection  of  the  distant 
parts  must  be  regarded  as  primary  in  character.  The  bacilli  have 
here,  possibly,  found  their  way  into  the  system  from  surfaces  that 
are  unaltered,  as  occasionally  happens  with  small  particles  of  foreign 
substances. 

Tuberculosis  of  the  meninges  in  the  majority  of  cases  is  either 
only  a  part  of  the  generalised  complaint,  or  is  secondary  to  disease 
of  the  ear.  In  a  few  instances  it  is  due  to  a  direct  extension  to  the 
meninges  of  tuberculous  disease  of  the  brain  or  cerebellum.  Not 
infrequently,  however,  it  is  apparently  primary  in  character,  no 
tuberculosis  being  found  elsewhere  in  the  body.  The  attending 
meningitis  is  most  marked  at  the  base  of  the  brain,  but  here  the 
resulting  fibrinous  effusion,  matting  the  parts  together,  may  be  so 
dense  as  to  mask  the  tuberculous  nature  of  the  disease.  The 
tubercles  are  found  in  the  greatest  numbers  in  the  fissure  of  Sylvius, 
vary  greatly  in  size,  and  when  very  minute  are  perhaps  more  easily 
felt  than  seen.  They  apparently  begin  in  the  perivascular  spaces 
surrounding  the  smaller  arteries,  and  accompany  the  arterioles  into 
the  meninges  and  the  brain  substance.  Along  with  the  meningitis 
there  is  always  a  varying  amount  of  cerebritis  as  well.  In  the 
greater  number  of  cases  of  tuberculous  meningitis,  tubercles  are 
present  also  in  the  choroid  plexus  of  the  ventricles. 


2  2^  MANUAL  OF   MEDICINE 

Tuberculosis  of  the  brain  substance  may  result  in  the  formation 
of  caseous  masses  varying  in  size  from  that  of  a  pea  to  that  of  a 
walnut.  In  the  brain  the'  individual  tubercles  and  the  masses  they 
form  are  larger  than  in  any  other  part  of  the  body.  In  recent  cases 
the  caseous  masses  are  apt  to  be  surrounded  at  their  circumferences 
by  a  layer  of  gray  miliary  tubercles.  The  tuberculous  tumours  are 
almost  invariably  multiple  in  number,  and  are  most  frequent  in  the 
cortices  of  the  cerebral  hemispheres,  the  cerebellum,  and  the  pons, 
in  the  order  given.  In  some  cases  they  give  rise  to  no  symptoms 
at  all,  and  are  only  revealed  by  post-mortem  examination.  In 
other  cases  they  produce  all  the  symptoms  of  cerebral  and  cerebellar 
tumours,  and  tubercle  accounts  for  the  larger  number  of  growths 
found  in  these  situations.  In  inf:ints  and  young  children  tuber- 
culous masses  in  the  cerebral  hemispheres  are  a  frequent  cause  of  a 
permanent  hemiplegia. 

Tuberculosis  of  the  peritoneum  may  occur  from  the  direct  per- 
foration of  an  ulcer  of  the  intestine  into  its  cavity,  or  as  only  a  part 
in  the  widespread  disease.  Not  unfrequently,  however,  usually  in 
childhood,  it  is  apparently  primary  in  character.  In  its  acute  forms 
the  peritoneal  surfaces,  both  visceral  and  abdominal,  are  studded 
with  very  numerous  gray  miliary  tubercles,  and  the  cavity  is  rapidly 
distended  with  the  out-poured  fluid.  In  more  chronic  cases  the 
peritoneum  is  greatly  thickened,  the  intestines  are  densely  matted 
together,  and  there  is  a  tendency  to  obliteration  of  the  peritoneal 
cavity. 

In  acute  general  tuberculosis  the  spleen  is  invariably  affected, 
and  in  a  large  proportion  of  cases  of  the  more  chronic  infection  it 
is  the  seat  of  tubercle.  Beyond  enlargement  of  the  organ,  never  of 
any  great  extent,  there  are  no  symptoms  or  physical  signs  attending 
tuberculous  disease  of  the  spleen. 

The  liver  is  affected  under  the  same  conditions  and  in  the  same 
proportion  of  cases  as  the  spleen,  and  in  addition  tubercles  on 
the  peritoneal  surface  may  penetrate  into  the  substance  of  the 
organ.  Tuberculosis  of  the  intestines,  too,  may  lead  to  that  of 
the  liver,  owing  to  the  virus  being  carried  to  the  last  by  means  of 
the  mesenteric  veins.  In  this  case  the  distribution  of  the  tubercles 
may  correspond  closely  with  that  of  the  portal  vessels.  As  a  rule, 
tuberculosis  of  the  liver  is  only  clinically  manifested  by  enlargement 
of  the  viscus.  Tuberculosis  of  the  portal  canals,  however,  may  give 
rise  to  an  overgrowth  of  connective  tissue,  and  cause  one  of  the 
forms  of  hj'pertrophic  cirrhosis  of  the  liver. 

Tuberculosis  of  the  kidney  occurs  in  two  distinct  forms.       In 


TUBERCULOSIS  229 

the  general  complaint  gray  miliary  tubercles,  or  small  caseous 
masses,  are  scattered  throughout  the  kidneys,  more  especially  in  the 
cortical  portions,  to  which  the  capsules  are  generally  adherent.  In 
the  other  form  the  lining  membrane  of  the  hilum  is  the  seat  of 
varying  degrees  of  ulceration  and  caseation  (tuberculous  pyelitis), 
which  lead  on  gradually  to  the  destruction  of  the  kidney.  From 
the  kidney  the  disease  spreads  to  the  ureter,  which  may  be  lined 
with  caseous  material  throughout  its  whole  course,  and  from  the 
ureter  the  disease  may  spead  by  continuity  to  the  bladder.  The 
kidney  is  more  or  less  enlarged  in  a  large  majority  of  cases  of 
tuberculous  pyelitis,  and  when  the  ureter  is  blocked  by  the  caseation 
there  may  be  a  condition  of  pyo-nephrosis.  Only  one  kidney  may 
be  affected,  and  when  both  are  attacked  one  is  generally  much  more 
affected  than  the  other. 

Tuberculosis  of  the  bladder  is  extremely  rare  as  a  primary 
manifestation,  and  is  generally  secondary  to  tuberculosis  of  the 
testicle  or  the  kidney. 

Tuberculosis  of  the  testis^  apparently  primary  in  origin,  is  far 
from  uncommon.  Here  it  attacks  the  epididymis,  and  an  indolent 
tumour  is  formed  which  almost  completely  surrounds  the  testicle. 
In  adults  and  older  children  the  disease  has  a  great  tendency  to 
extend  by  means  of  the  spermatic  channels  to  the  vesiculas  seminales, 
the  prostate,  the  bladder,  and  even  up  to  the  kidneys.  In  children 
under  the  age  of  seven  the  disease  usually  confines  its  ravages  to 
the  epididymis  itself,  and  a  chronic  abscess  often  forms  which  bursts 
through  the  scrotal  walls. 

Next  to  the  lymphatic  glands,  the  bones  and  joints  are  the  most 
frequent  sites  of  the  localised  complaint  in  childhood.  The  spongy 
portions  of  the  bones  are  the  parts  chiefly  affected,  and  in  the 
long  bones  it  is  the  epiphyses  entering  into  the  formation  of  the 
joints  that  are  mainly  involved,  leading  to  necrosis  of  the  cartilages 
and  infection  of  the  lining  membranes,  along  with  destructive 
changes  in  the  joints  of  a  greater  or  less  severity.  In  the  spinal 
column  the  contiguous  surfaces  of  adjacent  vertebrae  are  commonly 
affected,  and  it  would  seem  as  if  the  disease  had  started  in  the  inter- 
vertebral cartihiginous  discs,  but  owing  to  the  non-vascularity  of  the 
latter  such  an  origin  is  unlikely.  In  the  joints  the  complaint  may 
start  in  the  membranes  instead  of  being  an  extension  from  diseases 
of  the  bones.  Cases  commencing  in  disease  of  the  membranes  are 
usually  more  chronic  in  their  course  than  those  beginning  in  disease 
of  the  bones. 

It  is  not  uncommon  for  cases  that  have  for  a  lona;  tmie  been 


230  MANUAL   OF   MEDICINE 

essentially  of  the  chronic  and  localised  form  to  suddenly  take  on 
an  acute  and  generalised  character,  owing  to  the  entrance  of  the 
virus  into  the  general  blood  stream.  Such  an  occurrence  is  usually 
marked  by  an  access  of  fever  and  bodily  distress,  apart  from  any 
symptoms  arising  from  the  implication  of  fresh  organs  in  the  com- 
plaint. The  generalised  form  may  even  follow  upon  such  purely 
local  conditions  as  tuberculous  disease  of  the  bones. 

The  distribution  of  |ubercle  in  the  different  organs  in  the  general- 
ised disease  is  one  of  scientific  interest  rather  than  one  of  practical 
importance.  Many  published  lists  differ  widely  in  their  estimation 
of  the  frequency  with  which  the  different  organs  are  involved,  and 
this  is  bound  to  be  the  case  where  so  much  depends  upon  the  indi- 
vidual care  and  upon  accuracy  of  observation.  All  statistics,  however, 
agree  upon  the  rarity  with  which  the  lungs  escape.  This  is  doubtless 
owing  to  the  fact  that  in  extension  from  most  parts  of  the  body, 
whether  directly  by  the  blood  vessels  or  indirectly  by  means  of  the 
thoracic  duct,  the  bacilli  have  to  pass  ultimately  through  the  capil- 
laries of  the  lungs.  Out  of  sixty-three  cases  of  general  tuberculosis, 
tabulated  by  Dr.  Shardlow  at  the  East  London  Children's  Hospital, 
in  only  five  were  the  lungs  recorded  as  free,  and  in  two  of  these  five 
the  bronchial  glands  were  caseous.  Of  the  remaining  three,  in  one 
the  tubercles  were  almost  confined  to  the  pleura,  pericardium,  peri- 
toneum, and  meninges ;  in  one  the  peritoneum  and  meninges  were 
chiefly  affected ;  and  in  one  there  was  ulceration  of  the  intestines, 
with  caseation  of  the  mesenteric  glands.  It  is  noteworthy  that,  in 
all  the  sixty-three  cases,  in  one  only  the  disease  seemed  to  have  its 
primary  origin  in  the  intestinal  membranes.  In  the  same  cases  the 
liver  was  recorded  as  tuberculous  in  thirty-one  instances,  or  about 
fifty  per  cent.  This  possibly  understates  the  percentage  of  cases  of 
involvement  of  the  liver,  as  in  that  organ  the  tubercies  are  often  so 
microscopic  in  size  that  they  are  overlooked.  The  frequency  of 
tuberculosis  of  the  liver  is  no  doubt  due  to  the  virus  being  carried  to 
it  from  the  other  abdominal  organs  by  the  portal  vein. 

Influence  of  age  and  sex. — General  tuberculosis  is  infinitely 
more  common  during  the  first  two  years  of  life,  and  there  is  a 
lessening  tendency  to  it  wnth  each  year  of  life  up  to  the  age  of 
puberty,  after  which  it  is  comparatively  rare.  Tuberculosis  of  the 
bones  and  joints,  the  lymphatic  glands,  and  to  a  less  degree  the 
testicles,  is  most  frequent  in  childhood,  but  is  far  from  uncommon 
in  adult  age.  Chronic  pulmonary  tuberculosis  is  uncommon  under 
the  age  of  seven,  but  the  tendency  to  it  increases  with  every  year 
up  to  the  age  of  puberty.     It  is  most  frequent  between  this  last 


TUBERCULOSIS  231 

and  the  age  of  twenty,  and  after  this  decreases  with  each  decade  of 
life,  until  it  becomes  comparatively  rare  after  the  age  of  forty  as  a 
primary  complaint,  and  extremely  so  after  that  of  sixty.  Tuberculous 
meningitis  is  rare  under  the  age  of  six  months,  and  is  most  common 
between  this  age  and  that  of  puberty ;  but  it  is  much  more  common 
in  adults  than  is  generally  supposed.  As  a  whole  it  may  be  taken 
that  tuberculosis  is  commonest  in  childhood  and  early  adult  life, 
but  there  is  hardly  a  single  phase  of  it  that  may  not  occur  in 
extreme  old  age. 

There  are  no  reliable  statistics  showing  that  there  is  any  marked 
tendency  to  tuberculosis  in  the  one  sex  over  the  other.  It  is  the 
general  experience  that  the  progress  of  tuberculosis  is  frequently 
arrested  during  pregnancy,  to  develop  with  increased  virulence  after 
parturition. 

Contagiousness. — There  is  no  certain  proof  that  tuberculosis 
is  contagious  in  the  ordinary  sense  of  the  term  ;  but  that  one  person 
can  indirectly  contract  the  disease  from  another  is  incontestable. 
From  the  wide  prevalence  of  tubercle  bacilli,  both  in  the  air  and 
articles  of  food,  it  would  appear  that  less  importance  should  be 
attached  to  its  mere  presence,  and  more  to  the  element  of  predis- 
position to  the  disease.  That  the  members  of  certain  families  are 
specially  prone  to  the  disease  is  indubitable,  but  this  is  due,  not  to 
the  direct  transmission  of  the  virus,  but  to  a  hereditary  susceptibility 
to  contract  the  complaint,  or,  more  strictly  speaking,  to  a  lessened 
resistance  to  its  attack.  This  susceptibility  may  not  only  be  inherited, 
but  acquired.  It  is  principally  acquired  by  those  persons  in  whom 
the  general  health  is  reduced,  and  especially  by  those  in  whom  the 
respiratory  functions  are  placed  at  a  disadvantage.  Thus  tuberculosis 
is  most  common  amongst  the  inhabitants  of  over-crowded  dwellings, 
in  those  breathing  the  vitiated  air  of  factories,  and  in  those  exposed 
to  the  inhalation  of  finely  divided  dust.  Chronic  alcoholic  excess 
is  also  an  important  predisposing  cause.  There  is  not  only  a  pre- 
disposition on  the  part  of  certain  individuals  to  acquire  the  complaint, 
but  in  some  of  these  the  vulnerability  to  the  disease  may  rest  only 
in  particular  tissues  of  the  body.  It  is  only  by  the  conception  that 
the  vulnerability  is  restricted  to  certain  tissues  that  an  explanation 
can  be  found  of  the  simultaneous  affection  of  several  of  the  serous 
membranes  in  the  same  individual,  in  whom  the  rest  of  the  tissues 
escape.  Again,  it  is  not  uncommon  for  many  of  the  bones  of  the 
body  to  suffer  from  tuberculosis,  either  simultaneously  or  after  long 
intervals  of  time,  with  no  evidence  of  the  disease  in  other  parts. 
This  susceptibility  on  the  part  of  particular  tissues  may  be  inherited, 


232  MANUAL   OF   MEDICINE 

and  it  is  not  unusual  for  the  members  of  certain  families  to  die 
mainly  from  the  effects  of  the  complaint  on  the  cerebral  meninges, 
whilst  in  other  families  the  chief  stress  always  falls  on  the  lungs  or 
abdominal  organs. 

Curability.  —  Acute  general  tuberculosis  is  invariably  fatal. 
The  same  fatal  prognosis  attaches  to  tuberculous  meningitis,  as 
cases  of  recovery  are  too  exceptional  to  afford  any  reasonable 
grounds  for  hope  when  the  disease  is  well  marked  and  unmistak- 
able. The  majority  of  cases,  indeed,  of  reported  recovery  from 
tuberculous  meningitis,  as  Henoch  has  pointed  out,  have  probably 
been  examples  of  croupous  pneumonia  with  cerebral  symptoms 
where  the  diagnosis  has  been  at  fault ;  or  of  pneumococcal  menin- 
gitis secondary  to  the  lung  affection.  Cases  of  the  more  chronic 
form  of  general  tuberculosis,  even  where  there  is  evidence  of  many 
organs  being  involved,  may  undoubtedly  recover  temporarily,  but 
only  too  often  the  disease  recurs  with  a  fatal  termination.  Still, 
there  is  no  proof  that  all  such  cases  relapse,  and  the  fact  that 
temporary  recovery  is  possible  affords  reason  for  belief  that  in 
exceptional  instances  recovery  may  even  be  permanent  and  complete. 
In  most  other  cases,  except  perhaps  when  the  disease  is  far  advanced 
in  the  lungs  or  intestines,  tuberculosis  is  far  from  necessarily  fatal, 
and  complete  recover}'  may  occur.  Yer)'  often  post-mortem  examina- 
tions reveal  the  presence. of  unexpected  tuberculous  lesions  which 
had  long  been  recovered  from  and  become  obsolete,  and  in  many 
such  cases  there  is  no  history  of  the  patient  having  at  any  time 
suffered  from  tuberculosis.  In  numerous  instances,  too,  tuberculous 
disease  is  apparently  recovered  from,  but  only  to  recur  again  shortly 
after  the  onset  of  more  acute  disease,  such  as  one  of  the  exanthe- 
mata. Measles,  in  particular,  is  frequently  responsible  for  relighting 
up  quiescent  tuberculosis,  and  this  in  a  manner  beyond  its  mere 
power  of  setting  up  a  catarrhal  state  in  numerous  regions.  Some 
authorities,  too,  state  that  surgical  operations  often  convert  a  localised 
tuberculosis  into  one  of  the  generalised  form,  but  the  alleged  fre- 
quency of  this  occurrence  is  not,  perhaps,  in  accord  with  general 
experience. 

Clinical  symptoins. — In  every  case  where  there  is  any  wide 
distribution  of  tuberculous  disease  fever  is  a  marked  feature  of  the 
complaint.  The  fever,  too,  is  specially  characterised  by  its  irregular 
nature.  In  some  cases  the  temperature  is  high  in  the  mornings  with 
evening  remissions,  and  in  others  it  is  heightened  in  the  evenings 
with  remissions  nearly  to  the  normal  in  the  mornings.  These  two 
types  of  temperature,   again,   may  be  present  in  the  same  case  at 


TUBERCULOSIS  233 

different  stages  of  the  disease.  Death  may  ensue  from  the  general 
condition,  apart  from  any  disease  special  to  the  organs  involved  ;  and 
here  the  heightened  temperature  may  be  the  only  prominent  symptom 
during  life.  In  the  majority  of  cases,  however,  the  fever  is  accom- 
panied by  profound  pallor,  and  rapid  wasting  from  no  obvious  cause. 

Where  death  is  delayed,  in  addition  to  fever  and  wasting,  there 
are  often  symptoms  arising  from  the  implication  of  special  organs  in 
the  complaint.  Of  these  last,  the  lungs  undoubtedly  most  often 
furnish  evidence  of  being  attacked.  It  must  not  be  forgotten,  how- 
ever, that  the  lungs  may  be  extensively  riddled  with  tubercles  where 
the  physical  signs  are  healthy  both  to  auscultation  and  percussion. 
In  other  cases  the  only  evidence  of  extensive  involvement  of  the 
lungs  may  be  high-pitched,  somewhat  metallic  rales  audible  generally 
over  the  chest.  Where  the  disease  is  of  longer  standing,  there  may 
be  the  physical  signs  of  more  or  less  extensive  consolidation  of  the 
lungs  j  and  it  is  noteworthy  that  such  consolidation  is  most  frequent 
at  the  bases  instead  of  at  the  apices,  as  it  is  in  the  chronic  and 
localised  forms  of  the  complaint.  In  exceptional  instances  signs  of 
softening  and  cavitation  may  follow  upon  those  of  consolidation  in 
the  affected  lungs. 

Next  to  the  lungs  the  nervous  system  most  frequently  shows 
signs  of  special  implication  in  the  disease,  and  many  patients  with 
general  tuberculosis  die  with  head-retraction,  vomiting,  and  pro- 
gressive coma,  the  results  of  meningitis,  as  the  only  prominent 
evidences  of  the  widespread  complaint. 

In  a  minority  of  cases  the  chief  stress  of  a  general  tuberculosis 
falls  upon  the  abdominal  organs,  and  the  victims  may  die  apparently 
from  the  effects  of  a  protracted  and  incurable  diarrhoea.  In  rare  in- 
stances rose  spots,  indistinguishable  from  those  of  enteric  fever,  may 
occur  upon  the  abdominal  walls,  and  it  has  been  asserted,  but  on  no 
reliable  grounds,  that  such  spots  in  tuberculous  subjects  are  in- 
variably associated  with  disease  of  the  intestines.  The  spleen  is 
generally  enlarged,  and  this  splenic  enlargement  is  often  the  earliest 
physical  sign  of  general  tuberculosis.  In  young  infants,  who  are 
much  wasted,  hsemorrhagic  staining  is  common  upon  the  abdominal 
walls  and  elsewhere,  but  such  staining  may  occur  in  wasting  from 
other  complaints  besides  tuberculosis,  although  it  is,  perhaps,  most 
marked  in  the  last. 

In  many  cases  the  resemblance  of  the  symptoms  of  acute 
general  tuberculosis  to  those  of  enteric  fever  may  be  very  marked, 
and  in  the  early  stages  of  the  two  complaints  it  may  be  extremely 
difficult,  if  not  impossible,  to  distinguish  between  them.     In  tuber- 


234  MANUAL  OF   MEDICINE 

culosis,  however,  the  temperature  seldom  assumes  the  regular  rise 
and  daily  variations  characteristic  of  enteric  fever ;  the  tongue,  as  a 
rule,  is  less  furred ;  if  diarrhoea  be  present  the  stools  very  seldom 
present  the  typical  appearance  of  those  that  occur  in  enteric  fever ; 
wasting  takes  place  earlier  and  is  more  rapid  ;  and  there  is  a  greater 
tendency  to  early  and  progressive  coma.  All  these  distinctive  signs, 
however,  may  fail  us  ;  and  then  valuable  assistance  may  be  derived 
from  the  serum  test. 

It  must  be  remembered  that  the  presence  of  tubercle  favours 
invasion  by  staphylococci,  streptococci,  and  other  organisms,  and 
that  such  mixed  infection  is  frequently  met  with,  contributing  its 
own  symptoms  to  the  general  morbid  manifestations. 

Duration. — In  cases  of  acute  general  tuberculosis  death  is 
seldom  protracted  beyond  the  limits  of  three  weeks  or  a  month. 
The  same  time  may  be  fixed  as  the  limit  of  the  course  of  cases  of 
tuberculous  meningitis.  The  duration  of  the  less  acute  cases  of 
general  tuberculosis  is  usually  to  be  reckoned  by  months  rather  than 
by  years.  In  most  other  phases  of  the  complaint  the  duration  is 
dependent  on  so  many  factors  that  no  possible  general  rule  can  be 
adduced.  When  the  disease  is  restricted  to  non-vital  parts  death 
may  be  indefinitely  postponed,  and,  when  it  occurs,  is  usually  due 
to  the  supervention  of  acute  tuberculosis  or  to  the  lessened  resist- 
ance to  other  complaints  induced  by  the  original  disease. 

Treatment. — In  the  light  of  our  present  knowledge  the 
prognosis  of  general  tuberculosis  is  hopeless,  and  treatment  is 
practically  unavailing.  The  utmost  that  can  be  done  in  this  last  is 
to  control  temperature,  to  check  convulsions  and  diarrhoea,  and  to 
relieve  pain.  The  hopes  founded  on  tuberculin  a  few  years  back 
proved  a  failure,  and  its  use  in  many  cases  was  a  source  of  danger, 
if  not  of  positive  harm.  A  small  minority  of  cases,  however,  im- 
proved temporarily  under  this  agent  in  the  most  striking  manner. 
It  is,  perhaps,  in  the  direction  of  the  discovery  of  a  more  perfect 
tuberculin,  or  some  serum  remedy,  then,  that  hopes  should  rest 
in  the  future  treatment  of  the  established  disease.  If  at  present 
nothing  can  be  done  in  the  way  of  cure,  much  can  be  done  in  the 
way  of  prevention.  Improved  hygiene,  especially  the  ensurance  of 
abundance  of  fresh  air,  and  the  non-exposure  of  the  predisposed  to 
sources  of  infection,  would  guard  many  a  one  from  the  disease. 
The  services  of  the  surgeon,  too,  might  be  more  often  employed 
in  the  removal  of  scrofulous  glands  than  is  the  present  custom,  to 
prevent  the  spread  of  the  virus  to  more  vital  parts. 

.  .  J.   A.    COUTTS. 


LEPROSY  235 


LEPROSY 

A  chronic  specific  disease  tending  to  a  fatal  issue,  the  result  of 
infection  by  the  bacillus  leprce.  ;  characterised  by  the  formation  of 
granulomatous  infiltrations  of  the  skin  and  of  certain  nerves  and 
viscera,  which  induce  functional  irregularities  and  trophic  changes 
in  the  parts  affected. 

The  names  "elephantiasis  grsecorum  "  and  "lepra,"  which  have 
been  applied  to  the  malady,  are  liable  to  lead  to  confusion.  The 
former  is  apt  to  be  confounded  with  the  filarial  disease  elephantiasis 
arabum,  or  true  elephantiasis,  and  the  latter  is  a  term  employed  by 
Willan  to  designate  a  disease  having  nothing  in  common  with  leprosy 
except  a  cutaneous  resemblance.  Leucoderma,  a  common  condition 
more  particularly  amongst  the  yellow  races,  has,  owing  to  the  Biblical 
phrase,  "  a  leper  as  white  as  snow,"  come  to  be  viewed  with  suspicion 
without  any  reason. 

History. — Leprosy  seems  to  have  existed  among  all  the  ancient 
peoples  of  the  earth  who  have  recorded  their  histories,  whether 
Egyptians,  Jews  and  their  neighbours,  Hindoos  or  Chinese.  It  may 
fairly  be  assumed  also  to  have  existed  amongst  many  other  less 
literary  races  of  the  earth,  from  what  we  know  of  them  at  the 
present  day.  Although  leprosy  is  chronic  in  nature,  but  slightly 
contagious,  and  but  slowly  infectious,  it  would  seem  that  the  tide  of 
its  intensity  flows  and  ebbs,  and  that  waves  of  the  disease  pass 
over  portions  of  the  world  at  long  intervals.  In  ancient  and  medi- 
aeval times  we  find  countries  at  one  time  free  from  leprosy  being 
invaded  and  again  purged  of  the  disease.  Greece,  previously  free, 
seems  to  have  been  attacked  about  400  B.C.,  as  intercourse  with 
Egypt  increased,  and  the  Crusaders  appear  to  have  been  responsible 
for  leprosy  reaching  Western  Europe,  where,  after  establishing  itself 
for  some  300  or  400  years,  it  subsequently  receded,  until  at  the 
present  day  it  is  all  but  extinct.  On  the  other  hand,  in  modern 
times,  we  find  leprosy  reaching  countries  never  before  visited ;  of 
these  the  Hawaiian  group  of  islands  is  the  most  marked  example. 
Some  fifty  years  ago  the  disease  was  unknown  in  these  remote 
Pacific  Islands,  but  now  it  is  the  most  grievously  affected  part  in 
the  world. 

Geographical  distribution. — At  the  present  day  lepers  are  met 
with  in  increasing  numbers  as  the  equator  is  approached,  and  its 


236  MANUAL  OF   MEDICINE 

presence  is  in  inverse  ratio  to  sanitary  advance.  There  is  perhaps 
no  country  in  Europe,  Asia,  or  Africa  quite  free  from  the  malady. 
Of  European  countries  the  British  Isles  contain  perhaps  the  fewest, 
and  Norway,  in  proportion  to  population,  perhaps  the  greatest 
number  of  lepers.  In  Asia  two  great  leprous  centres  exist,  viz. 
Northern  India  and  Southern  China.  Siberia,  Japan,  the  Malay 
Peninsula,  Cochin  China,  Arabia,  Syria,  the  great  islands  of  Java 
and  Sumatra,  and  many,  but  by  no  means  all,  of  the  islands  of  the 
Eastern  Archipelago  are  tainted.  Australia  has  lepers  within  its 
seas,  but  they  are  for  the  most  part  Chinese,  as  are  the  majority  of 
lepers  in  the  Pacific  Archipelago. 

Africa,  North,  South  and  Central,  has  lepers  amongst  its  varied 
peoples.  In  the  best  known  parts  they  are  fairly  numerous,  as 
Egypt  in  the  north  and  as  Robin  Island  off  Cape  Colony  with  its 
leper  settlement  testify.  In  the  western  hemisphere  the  same  law 
holds  good,  namely,  that  as  the  equator  is  approached  the  number 
of  lepers  increases,  and  in  tropical  America  and  the  West  Indian 
Islands  the  disease  is  prevalent. 

Etiology. — The  bacillus  leprce  is  the  one  pathological  factor  in 
leprosy  which  requires  to  be  discussed.  Before  its  discovery  in 
187 1  the  supposed  causes  of  leprosy  were  multitudinous.  Amongst 
these,  want  of  salt,  malaria,  unwholesome  food,  scrofula  and  tuber- 
culosis, syphilis,  scurvy,  anaemia,  etc.,  each  had  its  advocates.  Mr. 
Hutchinson's  theory  that  the  consumption  of  uncooked  fish  is  the 
vehicle  of  contamination  in  leprosy  has  been  neither  proved  nor 
disproved,  and  many  arguments  for  and  against  the  idea  may  be 
adduced.  Heredity  finds  believers  and  disbelievers.  Against  the 
transmission  of  leprosy  from  parent  to  child  is  the  fact  that  no  child 
is  born  leprous,  and  that  the  suckling  of  a  leprous  mother  does  not 
exhibit  signs  of  leprosy.  It  is  seldom  before  the  third  year  that  a 
child  so  brought  up  becomes  leprous,  and  the  appearance  of  the 
symptoms  may  be  delayed  until  the  period  of  puberty.  All  clinical 
evidence  points  to  prolonged  and  intimate  contact  as  being  the  real 
channel  of  transmission.  From  husband  to  wife,  or  vice  versa  ;  from 
one  member  of  a  family  to  another,  more  especially  when  sleeping 
together ;  from  mother  to  child,  especially  if  the  child  is  breast  fed ; 
from  the  native  leper  to  the  healthy  European,  if  occupying  the  same 
bed  for  a  time ;  and  by  sexual  intercourse,  are  some  of  the  more 
direct  means  of  conveying  the  contagium  from  one  person  to  another. 
And  yet  intimate  contact  is  not  certainly  provocative.  The  writer 
saw  a  woman,  married  to  three  leper  husbands  in  succession,  and 
living  among  lepers,  in  the  leper  village  in  Canton,  who  was  perfectly 


LEPROSY  237 

free  from  any  leprous  taint  or  mark.  A  number  of  such  cases  are 
on  record,  showing  that  leprosy  is  by  no  means  highly  contagious  or 
infectious :  in  fact,  many  deny  the  propagation  of  leprosy  by  contagion 
at  all.  It  would  appear  that  leprosy  is  on  a  level,  in  this  point,  as 
in  many  others,  with  tuberculosis,  and  just  as  tubercle  is  occasionally 
conveyed  from  one  person  to  another,  so  it  would  seem  leprosy  is 
transmissible. 

Bacteriology. — The  microbes  of  tuberculosis  and  leprosy  are 
closely  allied  in  their  microscopic  appearance  and  in  their  reactions 
to  staining  fluids.  Specimens  of  the  bacillus  leprae  can  be  readily 
obtained  during  life  from  a  leprous  nodule  or  anaesthetic  patch 
which  has  been  rendered  bloodless  by  being  slowly  compressed 
between  the  blades  of  a  clamp  or  forceps.  When  the  pale  surface 
is  pricked  by  a  needle  in  several  places,  a  clear  lymph-like  fluid 
freely  exudes  from  the  punctures.  Specimens  of  the  bacillus  can 
be  obtained  in  pus  issuing  from  an  ulcer,  in  the  sputum  when  the 
disease  affects  the  mouth  or  larynx,  and  Horder  {Jourtial  of  Trap. 
Medicine,  Oct.  1899,  p.  68)  has  shown  that  the  microbe  is  also 
found  in  the  blood,  where  it  occurs  chiefly  in  the  leucocytes  but 
now  and  again  in  the  plasma. 

Post  -  mortem  specimens  of  the  leprosy  bacillus  are  readily 
obtained  from  any  leprous  granulomatous  tissue.  The  skin,  the 
nerve  sheaths,  the  lymphatic  glands,  the  liver  and  spleen,  are  richly 
endowed ;  but  in  lesser  luxuriance  it  is  also  present  in  the  ganglia  of 
the  spinal  cord,  in  the  endothelium  of  the  blood  vessels,  and  in  the 
liquor  sanguinis  or  leucocytes  of  the  blood.  The  bacillus  has  not 
been  proved  to  exist  in  bone,  muscle,  cartilage,  the  tissues  of  the 
brain,  the  walls  of  the  alimentary  canal,  the  kidneys  or  urine. 

The  following  method  of  staining  the  bacillus  in  the  blood,  recom- 
mended by  Horder,  gives  excellent  results  : — After  making  cover-glass 
preparation,  dry,  float  the  specimens  in  cold  carbol-fuchsine  solution  for 
twenty-four  hours,  wash,  pass  through  2  5  per  cent  sulphuric  acid,  wash 
again,  dry  and  counter-stain  with  methylene  blue. 

The  bacillus  of  tubercle  and  leprosy  are  so  similar  that  their 
descriptions  are  well-nigh  identical  (see  p.  220,  and  Plate  II.).  In 
one  or  two  points  only  are  they  to  be  differentiated.  {a)  The 
bacillus  leprae  when  stained  is  decolorised  less  readily  by  acids ;  {b) 
the  microbe  in  leprosy  occurs  almost  wholly  within  the  tissue  cells, 
in  marked  contrast  to  the  extra-cellular  disposition  of  the  tubercle 
bacillus ;  {c)  the  bacilli  in  leprosy  tend  to  become  aggregated  in 
colonies. 


238  MANUAL   OF   MEDICINE 

The  microscopic  appearance  of  the  bacilli  in  leprosy  is  typically 
a  straight  rod,  but,  just  as  in  tubercle,  club-shaped  and  branched 
forms  are  found.  Until  the  present  year  no  positive  evidence  of 
the  sustained  cultivation  of  the  leprous  bacillus  has  been  known. 
Dr.  Bevan-Rake  and  the  writer  both  reported  having  obtained 
single  cultivations  on  agar-agar  in  1893,  but  Dr.  Carrasquilla  of 
Bogota  asserts  that  he  has  successfully  cultivated  the  bacillus 
leprae  in  solidified  human  serum  and  on  beef  bouillon  prepared 
according  to  the  method  of  Thouiot  and  Masselin  {^British  Medical 
Joiirn.  July  1899).  Dr.  Carrasquilla  cultivated  the  bacillus  from 
serum  to  serum  and  bouillon  to  bouillon,  pure  cultures  always 
being  obtained.  The  same  observer  says  that  he  noticed  the 
ba'illus  to  be  mobile  in  two  stages  of  its  development  \  one  form 
consists  of  long,  slender  bacilli  moving  in  an  undulatory  manner ; 
and  the  other  form  occurs  as  short,  coarse,  almost  elliptic  bodies 
moving  in  a  straight  line.  Further,  Dr.  Carrasquilla  believes  he 
observed  flagella  proceeding  from  the  shorter  bacillus.  Professor 
Campagna  of  Rome  states  that  he  has  also  cultivated  the  bacillus 
leprae. 

So  far  it  has  been  found  impossible  to  produce  the  signs  of 
leprosy  in  any  lower  animal  by  inoculation. 

Period,  of  incubation. — This  appears  to  be  most  variable. 
Symptoms  would  seem  to  have  first  manifested  themselves  in  a  few 
weeks,  or  it  may  be  many  years,  after  exposure  to  infection. 

Symptoms. — For  months  or  even  years  before  leprosy  declares 
itself  the  patients  may  suffer  from  general  debility,  febrile  attacks, 
exhaustion  after  exertion,  rheumatic  pains  in  the  muscles,  neuralgia 
in  certain  nerve  areas,  epistaxis,  sweatings,  and  marked  mental 
depression.  Occasionally  there  is  complete  absence  of  all  pre- 
monitory symptoms. 

The  division  of  leprosy  into  "nodular"  and  "  ansesthetic  "  is  a 
mere  clinical  convenience,  since  in  all  cases  of  nodular  leprosy  there 
is  an  accompanying  affection  of  the  nerves  and  attendant  anaesthesia. 
The  attempt  to  multiply  names  by  giving  prominence  to  a  mere  sign 
or  symptom  is  neither  scientific  nor  useful;  such  names  as  "nerve 
leprosy,  "macular  leprosy,"  "lepra  Isevis,"  etc.,  are  of  this  nature 
and  do  not  assist  our  knowledge  of  the  disease.  For  clinical  con- 
venience, however,  the  division  into  "  maculo-anassthetic "  and 
"nodular"  aids  description,  although  these  forms  are  liable  to 
overlap. 

I.  Lepra  maculo- an-Esthetica. — The  first  characteristic 
symptom  which  appears  is  an  erythematous  or  pigmented  eruption 


LEPROSY  239 

on  the  skin.  The  spots  develop  gradually  or  suddenly,  accom- 
panied by  marked  fever.  All  the  spots  become  in  time  pale  and 
anaesthetic  in  the  centre,  and  possess  a  zone  of  red  and  blue 
vessels  at  the  circumference,  which  is  somewhat  elevated.  The 
spots  vary  in  size  from  a  diameter  of  a  quarter  of  an  inch  to  that 
of  a  crown  piece,  but  after  a  time  they  may  coalesce  and  embrace 
a  large  irregular  area,  the  margins  of  which  continue  to  extend 
until,  it  may  be,  the  whole  circumference  of  the  limb  is  involved. 
Frequently  the  eruption  is  symmetrical,  remarkably  so,  but  this  is 
by  no  means  a  constant  feature.  In  the  very  early  stages  the 
centres  of  the  affected  areas  become  hypersesthetic.  The  eruption 
may  be  seen  first  on  the  chest,  but  the  limbs  and  face  are 
very  soon  involved.  The  nerves  along  their  trunks  and  in  the 
area  of  their  distribution  show  signs  of  implication  in  the  patho- 
logical lesion.  Neuritis  increases  as  the  disease  advances,  and 
in  such  palpable  nerves  as  the  ulnar  and  peroneal,  where  they 
cross  the  bones,  they  are  to  be  felt  thickened  and  are  painful  to 
pressure.  In  consequence  of  the  neuritis,  neuralgia  supervenes, 
succeeded  by  anaesthesia  and  trophic  changes  in  the  part.  Bul- 
bous eruptions  appear  on  the  skin,  the  hair  falls,  the  sweat  glands 
become  functionless,  the  nails  become  brittle,  the  joints  of  the 
fingers  especially  become  swollen  and  tender,  the  tendons  of  the 
fingers  and  toes  contract,  and  the  muscles  of  the  forearm,  hand, 
legs  and  feet,  atrophy  and  become  paralysed.  Facial  paralysis  may 
render  shutting  the  mouth  and  eyelids  impossible.  The  muscular 
paralysis  is  in  no  sense  ataxic,  as  lepers  can  use  even  their  damaged 
hands  for  fine  work,  and  their  power  of  walking,  although  weakened, 
is  not  affected  when  their  eyes  are  closed.  In  time  ulcers  appear  on 
the  parts  of  the  sole  of  the  foot  subjected  to  most  pressure ;  the 
ulcers  may  be  shallow,  or  may  penetrate  to  the  bones  causing 
necrosis.  In  the  hands  also  a  similar  condition  obtains,  and  nothing 
is  more  common  than  to  find  a  leper  severely  scalded  in  consequence 
of  his  putting  his  anaesthetic  hand  into  very  hot  fluids.  In  the  hands 
and  feet  the  bones  may  atrophy,  necrose,  and  exfoliate,  so  that  mere 
stumps  are  left  at  the  wrist  or  ankle.  In  this  condition  the  patient 
is  a  piteous  object,  and  the  forlorn  aspect  is  added  to  by  the 
expressionless  face,  by  the  drooping  eyelids  and  lower  lip,  the 
epiphora  consequent  upon  the  everted  puncta,  and  it  may  be  the 
loss  of  an  eye  from  ulceration  and  giving  way  of  the  cornea  owing 
to  exposure  of  the  eyeball.  Towards  the  end  smell  and  taste  may 
be  lost,  gastric  catarrh  and  diarrhoea  are  common,  albuminuria  may 
supervene,  or  pulmonary  tuberculosis  may  carry  off  the  patient. 


240  MANUAL  OF  MEDICINE 

II.  Lepra  tuberosa. — The  exact  period  at  which  tubercular 
or  nodular  leprosy  comuiences  in  any  single  individual  is  well-nigh 
impossible  to  ascertain.  A  few  scattered  nodules  may  exist  for 
years,  and  the  patient  may  either  conceal  them  or  be  unaware  of 
their  significance.  After  a  time,  however,  a  fresh  crop  of  nodules 
appears,  and  the  process  is  repeated  at  longer  or  shorter  intervals. 
Accompanying  each  eruption  the  patient  is  attacked  by  rigors  and 
fever,  which  may  reach  103°  or  105°  F.,  and  last  a  day  or  two. 
With  each  fresh  eruption  the  old  nodules  soften  and  may  com- 
pletely disappear. 

This  disappearance  of  old  nodules  with  the  formation  of  new, 
accompanied  in  every  case  by  fever,  suggests  that  during  the  process 
the  bacilli  leprae  are  absorbed  and  re-deposited,  giving  rise  to  auto- 
infection.  There  are  several  arguments  in  favour  of  this  assump- 
tion as  to  the  manner  of  the  spread  of  the  leper  bacillus  or  its 
products  in  the  body.  Leprous  nodules  vary  in  size  from  a  grain 
of  rice  to  a  chestnut,  or  even  half  a  fair-sized  orange.  They  feel 
hard  and  inelastic,  and  attain  a  yellowish  tint  when  of  some 
standing.  They  are  usually  met  with  in  the  exposed  parts  of  the 
body,  viz.  the  face,  back  of  hands  and  wrist,  and  the  fronts  of  the 
legs,  but  afterwards  they  may  appear  anywhere  except  on  the  glans 
penis,  the  palms  of  the  hands,  the  soles  of  the  feet,  and  the  scalp. 
The  eyebrows,  forehead  and  cheeks,  early  present  signs  of  infiltra- 
tion, but  every  part  of  the  face  may  be  so  thickened  and  reddened 
that  a  "  leonine  "  aspect  ensues.  The  ears  become  thickened  and 
discoloured ;  the  eyelids  become  nodular ;  the  eyes  suffer  from 
keratitis  or  iridocyclitis,  resulting  in  loss  of  sight.  The  mucous 
membrane  of  the  nose  is  infiltrated  and  leads  to  destruction  of  that 
part  of  the  nose  supported  by  cartilage.  The  mucous  membranes 
of  the  cheek,  tongue,  gums,  pharynx  and  larynx  become  infiltrated 
and  nodular,  leading  to  ulceration  and  possibly  partial  paresis  of 
the  laryngeal  muscles. 

The  lymphatic  glands  in  anatomical  relation  with  the  affected 
parts  in  both  nodular  and  maculo-angesthetic  leprosy  are  always 
somewhat  enlarged,  although  they  never  suppurate.  The  nerves  in 
nodular  leprosy,  as  in  the  maculo-ansesthetic,  are  subject  to  infil- 
tration and  neuritis,  with  consequent  neuralgia,  but  this  lesion 
develops  later  in  the  former  than  in  the  latter  disease.  The  testicle, 
liver,  and  spleen,  are  always  the  seat  of  leprous  infiltration  in  the 
nodular  variety;  the  testicular  tissue  becoming  wholly  atrophied, 
and  supplanted  by  fibrous  material.  As  the  disease  advances  nodules 
come  and  go,  but  the  actual  number  increases  with  each  attack  of 


LEPROSY  241 

fever.  These  eruptions  and  attacks  of  fever  may  supervene  every 
few  years,  then  every  year,  or  several  attacks  may  occur  yearly. 
The  nodules  may,  however,  become  stationary  and  ultimately  burst, 
ulcerate,  and  then  heal,  leaving  a  scar.  In  the  course  of  time 
ulceration  often  leads  to  lardaceous  degeneration,  or  tuberculosis 
ensues,  and  is  finally  fatal  after  some  eight  or  ten  years. 

The  nodules  of  leprosy,  when  cut  into,  appear  white  and  homo- 
geneous, and  the  tissue  beneath  the  microscope  is  seen  to  consist 
of  round,  epithelioid  and  spindle-shaped  cells,  and  scattered  amongst 
the  cellular  elements,  connective  tissue  and  a  few  blood  vessels. 

Diagnosis. — The  nodular  variety  of  leprosy  is  usually  so  pro- 
nounced in  character  that  there  is  but  little  chance  of  any  mistake 
arising.  Large  nodules,  however,  when  few  in  number,  are  some- 
times mistaken  for  Keloid  growths,  or,  again,  the  nodules  may  be  so 
small  that  only  by  microscopic  examination  and  finding  the  bacillus 
can  a  decided  opinion  be  given.  The  maculo-ansesthetic  form  of 
the  disease  in  the  commencing  stages  is  more  difficult  to  diagnose, 
but  the  early  anaesthesia  and  the  lymphatic  gland  enlargement  are 
usually  sufficient  to  determine  its  character.  Charcot  mentions  and 
differentiates  between  the  lesions  of  syringo-myelia  and  leprosy. 
As  in  the  former  there  are  neither  maculae,  thickened  nerve  trunks, 
nor  enlarged  glands ;  there  is  no  occasion  for  confusion  to  the 
careful  observer.  Tertiary  syphilis  perhaps  exhibits  lesions  which 
resemble  some  leprous  conditions  more  closely  than  any  other 
disease.  The  means  of  diagnosis,  however,  is  always  at  hand, 
namely,  the  demonstration  of  the  lepra  bacillus. 

The  leper  is  subject  to  many  skin  affections  which  may  obscure 
the  real  disease.  Scabies  is  a  common  accompaniment,  but  eczema, 
lichen,  psoriasis,  etc.,  are  often  met  with. 

Prognosis.  —  Leprosy  is  essentially  a  chronic  disease,  but 
occasionally,  owing  to  rapid  exhaustion  of  strength,  some  fatal 
intercurrent  affection  supervenes  within  a  year  or  two.  Nodular 
leprosy  is  much  more  acute  than  the  maculo-anaesthetic  variety ;  the 
average  lifetime  of  the  leper  afflicted  with  the  former,  after  the 
malady  declares  itself,  is  eight  to  ten  years.  But  in  the  case  of  the 
latter,  Jife  may  be  prolonged  for  a  period  of  fifteen  to  twenty  or 
even  forty  years. 

The  patient  succumbs  usually  to  phthisis,  pneumonia,  nephritis, 
or  amyloid  degeneration  of  the  viscera.  So-called  spontaneous 
cure  is  recorded,  but  it  would  seem  to  be  merely  a  cessation  of 
infection,  the  nodules  disappearing  to  be  succeeded  by  a  scarred 
anaesthetic  patch.      "  In  the  maculo-anaesthetic  form  the  cure  of  the 

VOL.  I  R 


242  MANUAL  OF  MEDICINE 

leprosy  is  almost  invariably  the  result "  (Hausen  and  Looft).  On 
excellent  authority  it  would  seem  that  leprosy  may  disappear  and 
leave  a  healthy  man,  but  the  rule  is  that  a  maimed  and  mutilated 
being  is  left  to  continue  a  miserable  existence. 

Treatment. — There  is  no  specific  treatment  for  leprosy ;  many 
drugs  have  been  announced  as  such,  but  a  temporary  reputation  is 
all  that  any  one  of  them  has  attained.  The  destruction  of  the 
bacillus,  either  by  medicinal  or  hygienic  treatment,  is  what  has  to 
be  aimed  it.  With  this  intention  Unna  introduced  pyro-gallol  and 
chrysarobin  and  Dr.  Danielssen  the  salicylates.  The  ointment 
employed  by  Unna  for  application  to  the  body  consists  of: — 
chrysarobin,  5  per  cent ;  salicylic  acid,  2  per  cent ;  ichthyol,  5  per 
cent;  lard  to  100.  When  the  ointment  is  for  the  face  Unna  re- 
commends pyrogallic  acid,  6  parts  ;  salicylic  acid,  2  parts;  ichthyol, 
5  parts;  lard  to  100  parts.  The  administration  of  10  drops  of 
acid  hydrochloric  dil.,  twice  or  thrice  daily,  counteracts  the 
deleterious  action  of  the  pyrogallic  acid.  The  writer  had  very 
gratifying  results  in  numbers  of  cases  of  leprosy  treated  in  this 
manner.  Chaulmoogra  oil  has  attained  a  considerable  reputation  ; 
10  drops  and  upwards  are  given  in  milk  twice  daily  ;  and  externally 
it  is  applied  with  olive  oil  (i  in  16)  as  an  embrocation,  which  is 
allowed  to  remain  on  the  skin  for  some  hours  and  then  washed  off 
with  soap  and  water.  Gurjon  oil  has  been  employed  in  a  similar 
manner. 

Dr.  Danielssen's  treatment  is  perhaps  the  most  satisfactory. 
The  general  health  of  the  patient  is  first  improved  by  good  food, 
and  the  administration  of  cod-liver  oil,  iron  and  quinine.  When 
the  general  condition  is  fairly  good  15  grains  of  salicylate  of  soda 
is  administered  three  or  four  times  a  day.  The  dose  may  be 
gradually  increased,  and  its  use  continued  for  six  or  twelve  months. 

The  writer  has  employed  almost  every  drug  recommended  for 
leprosy  by  the  Chinese,  but  with  no  marked  benefit ;  and  besides 
these  creasote,  phosphorus,  arsenic,  mercury,  aristol,  naphthol, 
and  salol,  etc.,  with  similar  unsatisfactory  effects. 

Koch's  tuberculin  was  first  tried  by  the  writer  on  an  extensive 
scale,  as  many  as  fifteen  lepers  being  under  treatment  at  a  time. 
A  certain  number  responded  to  the  treatment,  but  in  a  few  no  effect 
was  produced.  In  some  the  effect  was  most  marked,  almost  all 
cutaneous  signs  of  leprosy  disappearing  after  the  initial  fever  had 
subsided.  In  several  cases  coolies  who  suffered  from  leprosy,  and 
who  had  been  driven  off  by  their  fellow-labourers  from  working 
alongside  of  them  were,  after  treatment  by  tuberculin,  received  back 


MYCOSES  243 

amongst  them   as    "cured."       Unfortunately   the   beneficial   effects 
were  transitory. 

A  curative  serum  has  been  prepared  and  employed,  but,  so  far, 
with  dubious  results. 

Surgically  the  leper  may  require  :  —  to  have  tracheotomy  per- 
formed ;  operations  for  ectropion,  iridectomy,  etc.  •  removal  of  dead 
bone  when  the  bones  of  the  hands  and  feet  necrose  ;  nerve  stretching 
in  cases  of  anaesthesia,  etc.  When  the  nerve  trunk  supplying  a 
paralysed  area  is  stretched  and  incised  longitudinally,  the  sensation 
may  return  and  the  muscular  power  reappear  for  a  time. 

Prophylaxis. — Complete  segregation  of  lepers  with  separation  of 
the  sexes  is  the  only  known  system  whereby  the  spread  of  leprosy 
may  be  held  in  check. 

James  Cantlie, 


MYCOSES 

In  addition  to  animal  and  bacterial  parasites  the  human  body 
is  liable  to  be  attacked  by  a  number  of  vegetable  parasites,  and 
more  especially  by  certain  fungi ;  and  although,  strictly  speaking, 
bacteria  belong  to  the  vegetable-  kingdom,  it  is  convenient  to  dis- 
tinguish the  diseases  due  to  bacterial  invasion  from  those  dependent 
on  the  parasitic  activity  of  fungi  and  other  similar  organisms. 

The  number  of  fungi  that  are  found  either  associated  with  or 
actually  causative  of  pathological  lesions  in  man  is  daily  increasing. 
It  has  long  been  known  that  certain  skin  diseases  are  dependent  on 
the  presence  of  these  organisms,  but  it  is  only  comparatively  recently 
that  other  diseases  have  been  found  to  be  associated  with  or  de- 
pendent on  the  presence  of  such  vegetable  parasites  as  the  fungi. 

The  most  important  of  these  maladies  are  those  known  as 
actinomycosis  and  aspergillar  mycosis,  but  it  is  convenient  to  give 
the  name  of  mycosis  to  the  entire  group,  including  under  this  such 
diverse  affections  as  various  forms  of  dermatitis,  otitis  media,  and 
possibly  certain  tumours. 

Various  species  of  Blastomycetes  (saccharomyces)  have  been  found 
associated  with  a  number  of  inflammatory  states  usually  chronic  in 
character,  such  as  otitis,  less  often  running  a  definite  pyemic  course. 
Further,  these  fungi  have  been  found  in  other  conditions  besides 
inflammation.     Thus  a  cystic  growth  of  the  tibia  has  been  recorded 


244  MANUAL   OF   MEDICINE 

where  the  broken-down  material  in  the  cyst  contained  a  large 
number  of  saccharomyces,  and  in  this  case  a  general  pya^mic 
infection  occurred  and  the  metastatic  foci  contamed  the  same 
organism. 

Several  observers  have  described  the  presence  of  yeast -like 
organisms  (blastomycetes)  in  malignant  growths,  both  sarcomatous 
and  carcinomatous.  In  many  of  the  cases  of  inflammatory  lesions, 
and  perhaps  in  some  of  the  malignant  cases,  the  presence  of  the 
fungus  may  be  due  to  accidental  causes  and  to  secondary  infection, 
the  fungus  being  a  saprophyte  and  not  the  cause  of  the  lesion.  In 
others,  however,  it  is  apparently  definitely  parasitic  and  pathogenetic, 
since  the  inoculation  of  animals  with  a  culture  of  the  fungus  has 
led  to  the  formation  of  similar  lesions  to  those  occurring  in  the 
human  subject.  In  addition  to  various  species  of  blastomycetes, 
Mucor,  Penicillmm,  Aspergillus,  and  other  fungi  have  been  found 
associated  with  a  variety  of  pathological  states,  both  in  the  human 
subject  and  in  warm-blooded  animals.  The  spores  of  Penicillin m, 
when  injected  experimentally  into  animals,  cause  not  only  emboli, 
but  a  mycelium  is  under  certain  circumstances  produced,  which 
extends  inside  the  vessels  and  passes  through  their  walls  into  the 
adjacent  tissues,  and  its  presence  here  is  asserted  to  cause  a  fatty 
and  granular  degeneration  of  the  tissues,  and  death  may  result. 

The  infection  caused  by  some  of  these  fungi,  and  more  especially 
that  produced  by  actinomyces  and  aspergillus,  is  characterised  by 
the  formation  of  granulomata  which  resemble  superficially  those 
produced  by  the  virus  of  syphilis,  or  tubercle,  or  glanders ;  the  last 
two  disorders  at  any  rate  are  definitely  proved  to  be  of  microbic 
origin,  and  thus  the  lesion  produced  by  the  fungi  resembles  that 
produced  by  certain  microbes  ;  but  whereas  the  microbes  produce, 
in  addition  to  granulomata,  toxins  which  often  exe:t  a  poisonous 
effect  on  the  body  at  large,  the  fungi  apparently  produce  all  their 
pathological  effects  either  mechanically  or  by  interfering  with  the 
oxidation  of  the  tissues,  and  there  is  no  evidence  either  in  the  case 
of  actinomycosis  or  of  aspergillar  mycosis  of  the  production  of  any 
toxin. 

The  most  important  mycoses  clinically  are  actinomycosis,  madura 
foot  and  aspergillar  mycosis. 

Actinomycosis 

Actinomycosis  is  an  infectious  malady  characterised  by  the 
formation     of    granulomata,   affecting     man     and     many    domestic 


MYCOSES  245 

animals,  and  is  dependent  on  the  growth  of  an  organism  belonging 
to  the  genus  Oospora  according  to  some  authors,  but  it  is  more 
usually  described  as  a  species  of  Streptothrix.  The  disease  is  more 
especially  prevalent  in  cattle,  the  jaws  and  tongue  being  the  parts 
most  frequently  affected,  but  it  is  also  found  widely  disseminated 
in  the  internal  organs.  It  is  rare  in  horses  and  donkeys,  and  occurs 
occasionally  in  the  pig  and  sheep.  In  some  herds  of  cattle  it  has 
been  observed  to  the  extent  of  8  per  cent,  and  it  is  said  to  be 
especially  prevalent  in  the  fen  country. 

In  the  human  subject  from  50  to  80  per  cent  of  the  cases 
attack  primarily  the  cervico-facial  region,  including  the  mouth.  The 
abdomen  and  chest  are  next  most  frequently  affected,  and  the  skin 
and  limbs  are  the  least  often  involved. 

Histology. — The  actinomyces  occur  in  the  form  of  yellowish- 
green  grains,  the  largest  of  which  are  the  size  of  a  pin's  head,  and 
of  rather  irregular  oval  or  reniform  outline.  These  are  found  in  the 
depths  of  the  tissue  affected  and  also  in  the  pus.  Each  grain  con- 
sists of  a  central  portion  composed  of  a  mycelium,  and  at  the 
periphery  are  found  the  characteristic  clubs  arranged  more  or  less 
irregularly.  In  addition  to  these,  spores  of  i  to  2  /a  are  scattered 
through  both  the  central  and  peripheral  portions  of  the  granules, 
but  most  abundantly  in  the  former  situation.  The  most  constant 
structure  in  the  actinomycotic  granule  is  the  mycelium  (Plate  I.). 
This  consists  of  threads  of  from  i  to  2  /x  in  breadth,  and  varying 
from  3  to  100  ^  in  length.  The  growth  of  the  organism  occurs  by 
^the  formation  of  spores,  and  these  spores  are  developed  from  certain 
filaments  which  are  rather  thicker  and  more  differentiated  than  the 
neighbouring  ones.  It  was  formerly  thought  that  the  clubs  were  also 
concerned  in  the  process  of  reproduction,  but  more  recently  it  has 
been  demonstrated  that  the  club  formation  depends  on  hyaline 
degeneration  of  the  peripheral  portion  of  the  filament  constituting  a 
kind  of  sheath.  The  cultivation  of  actinomyces  is  difficult,  but  it 
can  be  grown  in  peptonised  broth  and  on  agar,  and  it  develops 
readily  on  the  moist  surfaces  of  cereals  at  a  temperature  of  35°  to 
37°  C.  Inoculated  into  animals  it  grows  with.facility  in  the  peritoneal 
cavity  of  the  rabbit,  but  it  is  difficult  to  obtain  virulent  cultures. 

Mode  of  infection. — The  malady  has  been  communicated  to 
man  by  contact  with  animals  affected,  but  this  is  rare,  and  it  is 
seldom  one  infected  animal  conveys  the  disease  to  another.  It  is 
more  usual  for  the  human  subject  to  become  infected  through 
barley  and  rye,  both  of  which  are  frequently  affected  with  the  fungus. 
Infection  is  probably  caused  by  chewing  the  fresh  grains,  which  have 


246  MANUAL  OF  MEDICINE 

been  actually  found  in  the  seat  of  the  lesion.  The  presence  of 
carious  teeth  is  undoubtedly  an  important  predisposing  cause. 
Cereals  are  not  the  only  materials  by  which  the  disease  is  com- 
municated, and  numerous  instances  have  occurred  where  the  disease 
has  developed  as  the  sequel  to  a  wound  produced  by  a  splinter  of 
wood,  but  the  infecting  agent  usually  enters  the  body  either  through 
the  digestive  tube  or  the  respiratory  tract. 

Course  and  symptoms. — Clinically  the  disease  presents  itself 
in  two  forms.  In  the  one  the  lesion  simulates  to  a  greater  or  less 
extent  a  new  growth ;  in  the  other  it  is  more  definitely  inflam- 
matory, and  leads  to  suppuration,  but  even  in  the  latter  case  the 
abscesses  formed  are  characteristic  in  being  surrounded  by  extensive 
chronic  inflammation  and  induration,  so  that  they  have  exceedingly 
thick  walls.  The  likeness  to  a  new  growth  is  owing  to  the  fact  that 
the  actinomycotic  tumours  are  granulomata,  and  the  resemblance 
is  especially  great  when  the  face  and  jaws  are  attacked  and  the 
malady  has  existed  for  some  time.  The  differential  diagnosis  from 
malignant  disease  is  difficult  in  the  early  stages.  After  a  time, 
however,  portions  of  the  growth  break  down  into  pus,  and  this 
ultimately  reaches  the  surface  through  long  fistulous  channels.  A 
very  characteristic  appearance  is  for  one  side  of  the  face  and  neck 
to  be  occupied  by  a  tense  brawny  swelling,  covered  with  livid  and 
congested  skin,  in  which  are  several  ulcerated  sinuses  discharging 
pus.  The  association  of  the  mass  with  a  purulent  discharge  is  very 
characteristic.  Similar  tumours  not  uncommonly  involve  the  jaws, 
the  floor  of  the  mouth  or  the  tongue,  and  in  all  cases  they  have  the 
characteristics  described  above.  It  is  probably  impossible  to 
diagnose  the  disease  until  a  certain  amount  of  breaking  down  has 
occurred.  The  pus,  usually  inodorous,  often  contains  the  yellowish- 
green  grains  characteristic  of  actinomyces,  which  somewhat  resemble 
particles  of  iodoform,  and  are  easily  visible  to  the  naked  eye.  In 
the  abdomen  the  liver  is  most  frequently  the  seat  of  the  deposit  of 
actinomyces,  and  the  appearance  produced  here  is  also  very 
characteristic.  The  organ  may  be  greatly  enlarged  and  contain  a 
mass  the  size  of  a  foetal  head  or  even  bigger.  On  section  the  tumour 
is  yellow  or  greenish  yellow  in  colour,  and  has  frequently  a  peculiar 
arborescent  appearance,  especially  in  the  more  peripheral  portion  of 
the  growth,  the  structure  consisting  of  a  dense  fibrous  framework,  the 
meshes  of  which  are  occupied  by  softer  purulent  material,  which 
can  be  washed  away.  Occasionally  there  are  multiple  foci  and 
still  more  frequently  the  disease  spreads  from  the  liver  through  the 
diaphragm  into  the  lung,  as  the  mode  of  growth  is  almost  always  by 


MYCOSES  247 

continuity.  Actinomycotic  tumours  thus  resemble  aneurism  in  their 
mode  of  extension,  involving  and  destroying  all  the  tissues  without 
any  regard  to  anatomical  limitations.  Sometimes  the  growth  spreads 
so  as  to  involve  the  abdominal  and  costal  parietes,  and  ultimately 
reaches  the  surface,  a  long  fistulous  and  sinuous  track  surrounded 
by  dense  fibrous  tissue,  discharging  externally  the  pus  which  may  be 
formed  at  a  great  depth  in  the  liver,  lung,  or  other  viscus.  It  is 
probable  that  in  all  cases  of  apparent  primary  actinomycosis  of  the 
liver  that  the  real  primary  seat  of  the  mischief  has  been  in  the 
appendix,  or  some  other  portion  of  the  alimentary  canal.  Actinomy- 
cotic deposits  in  the  right  iliac  fossa  in  connection  with  the  appendix 
are  not  uncommon,  undoubtedly  occurring  more  frequently  than  is 
supposed,  inasmuch  as  the  diagnosis  is  difficult,  unless  the  pus  is 
examined  microscopically.  Occasionally  cases  have  been  recognised 
by  the  miicroscopical  examination  of  the  faeces,  the  characteristic 
grains  have  been  found,  and  have  at  once  cleared  up  the  nature  of 
the  hard  dense  tumour-like  mass  occupying  the  iliac  fossa.  In  these 
cases  of  actinomycotic  appendicitis  there  is  usually  great  induration, 
so  that  the  pus  may  only  be  reached  by  incising  a  mass  of  fibrous 
tissue  perhaps  an  inch  thick,  and  it  is  for  this  reason  that  the  lesion 
in  this  neighbourhood  is  peculiarly  apt  to  be  mistaken  for  malignant 
disease. 

Actinomycosis  of  the  lung  may  be  primary,  in  which  case  the 
causal  organism  is  supposed  to  have  been  inhaled,  or  it  may  extend 
from  some  neighbouring  part,  as  the  oesophagus  or  liver  or  even  the 
root  of  the  neck ;  or  the  lung  may  contain  numerous  metastatic 
deposits  reaching  it  through  the  blood  from  some  primary  mass 
elsewhere.  Some  cases  have  been  described  where  the  lungs  were 
studded  with  minute  nodules  simulating  those  of  tubercle ;  more 
frequently,  however,  the  disease  in  the  lung  leads  to  the  formation 
of  a  tumour-like  mass,  in  which  a  cavity  or  cavities  containing 
pultaceous  puriform  material  are  found ;  these  are  surrounded  by 
dense  fibrous  tissue  which  spreads  irregularly  through  the  lung,  and 
so  produces  an  appearance  verj'  similar  to  that  seen  in  some  forms 
of  malignant  growth.  The  bases  are  more  liable  to  be  affected  than 
the  apices.  It  may  lead  to  the  production  of  pleurisy  or  of  empyema, 
or  may  even  spread  and  involve  the  chest  wall  and  discharge  ex- 
ternally much  in  the  same  way  as  in  hepatic  actinomycosis. 

In  the  case  of  the  skin,  growths  simulating  sarcomata  in  their 
softness  and  their  general  appearance  are  produced,  but  very  soon 
ulceration  of  the  integument  occurs  with  the  formation  of  crater-like 
ulcers  discharging  the  characteristic  pus. 


2  48  MANUAL   OF   MEDICINE 

Lymphatic  glands  are  not  commonl)-  affected  in  actinomycosis, 
the  virus  being  disseminated  more  usually  through  the  blood  stream, 
and  even  when  the  disease  has  produced  a  large  mass  breaking  down 
and  ulcerating  in  places,  it  is  exceptional  to  detect  clinically  any 
marked  glandular  enlargement. 

The  general  symptoms  include  more  especially  fever  and  wasting. 
Mechanical  effects  dependent  upon  the  anatomical  position  of  the 
lesion  are  necessarily  present  in  many  cases.  Cough,  in  the 
pulmonary  form  of  the  disease,  is  a  prominent  symptom,  more 
especially  in  the  "  bronchitic  "  type  of  the  malady.  The  fever  is, 
as  a  rule,  moderate  in  its  intensity,  rarely  exceeding  103",  and  more 
usually  not  rising  above  101°.  The  course  of  the  fever  is  very 
similar  to  that  seen  in  chronic  suppuration.  The  disease  is  usually 
chronic.  It  may,  however,  run  an  acute  course,  more  especially 
when  complicated  by  secondar)-  affections. 

Diagnosis. — \Mien  a  tumour  is  produced  which  can  be  felt  the 
principal  error  that  is  made  is  to  confound  it  with  a  mahgnant 
growth  such  as  a  sarcoma.  '\^Tien  the  growth  has  caused  ulcera- 
tion, as,  for  instance,  in  the  neck  or  in  the  tongue,  it  is  liable  to  be 
confounded  %vith  epithelioma.  The  occupation  of  the  patient 
rendering  him  liable  to  infection,  and  more  especially  the  examina- 
tion of  the  pus,  will  throw  light  on  the  nature  of  these  cases,  which 
are,  however,  always  obscure. 

In  visceral  actinomycosis  the  diagnosis  is  still  more  difificult, 
unless  a  sinus  has  formed,  owing  to  the  disease  having  spread  to 
the  surface  of  the  body;  usually  the  case  will  only  be  recognised 
during  an  operation,  unless  the  characteristic  grains  have  been 
found  in  a  discharge  or  in  the  faeces.  The  case  will  probably  be 
looked  upon  as  one  of  malignant  disease,  or  perhaps  as  one  of 
abscess. 

In  the  case  of  pulmonar}^  actinomycosis  it  is  most  apt  to  be 
confounded  with  tuberculosis,  since  it  so  frequently  produces  a 
persistent  bronchitis  and  recurrent  pleurisy  and  effusion,  and  here 
also  the  diagnosis  can  only  be  made  in  the  earlier  stages  by  a 
microscopic  examination  of  the  expectoration.  In  the  fully  estab- 
lished and  later  stages  of  the  disease  the  characteristic  involvement 
of  the  chest  waU  and  the  formation  of  sinuses  wiU  reveal  the  nature 
of  the  case. 

Treatment. — Some  forms  of  actinomycosis,  as  for  instance  the 
cervdco-facial,  the  buccal,  and  actinomycotic  appendicitis,  are  fairly 
amenable  to  surgical  interference ;  this  is  more  difificult,  but  not  im- 
possible, where  the  malady  is  deep-seated  in  the  lungs  or  liver.     The 


MYCOSES  249 

hEemorrhage  from  scraping  actinomycotic  sinuses  is,  however,  some- 
times very  excessive. 

Pulmonary  and  visceral  actinomycosis  are  often  beyond  the 
reach  of  surgery,  and  are  most  suitably  treated  by  the  administra^ 
tion  of  iodide  of  potassium,  which  has  a  very  great  influence  on  the 
malady  both  in  man  and  in  animals.  Large  doses,  20  to  30  grains 
three  times  a  day,  are  necessary,  and  this  drug  is  also  of  consider- 
able value  in  the  treatment  of  the  other  forms  of  the  disease  involving 
the  face,  skin,  neck,  and  tongue.  Different  observers  estimate  the 
value  of  this  drug  differently,  but  it  seems  certain  that  only  a  small 
proportion  of  cases  are  really  cured  by  its  administration  even  in 
large  doses.  Tonics  and  a  liberal  diet  are  necessary  to  counteract 
the  general  weakness. 

When  the  disease  involves  the  skin  and  subcutaneous  tissues  the 
local  treatment  should  consist  in  the  applicaLion  of  some  antiseptic 
ointment  or  dressing,  such  as  boracic  ointment,  cyanide  gauze,  or 
boracic  lint,  preceded  by  thorough  scraping,  and  sometimes  with 
advantage  chloride  of  zinc  may  also  be  used.  Iodoform  should  not 
be  employed. 

Mycetoma  or  madura  foot  is  an  affection  of  the  subcutaneous 
structures  of  the  foot,  very  similar  to  that  produced  by  actinomyces, 
and  the  resemblance  between  the  lesions  seen  in  the  cervico-facial 
form  of  actinomyces  and  Madura  foot  is  very  close.  The  same 
brawny  sweUing  with  fistulous  sinuses  and  projecting  fungoid  granu- 
lation tissue  are  seen  in  both  conditions.  The  tissues  of  the  foot 
are  infiltrated  with  a  mycelium  which  is  now  recognised  as  the 
cause  of  the  disease.  The  myceUum  of  Madura  foot  resembles 
that  of  actinomyces,  but  the  spores  seen  in  the  latter  have  not 
been  detected  as  yet  in  the  former.  Two  varieties  of  the  disease 
are  recognised,  one  where  the  infiltrated  tissues  are  pigmented,  the 
so-called  melanoid  form ;  the  other  where  the  lesion  is  colourless. 
The  black  pigmentation  is  usually  regarded  as  dependent  upon 
degeneration  of  the  fungus.  Some  observers  have  thought  that  two 
distinct  varieties  of  fungus,  one  black  and  one  white,  exist.  The 
disease  is  more  especially  prevalent  in  India,  and  is  probably 
dependent  upon  direct  infection  of  the  naked  foot. 

ASPERGILLAR    MyCOSIS 

The  aspergillus  has  been  found  in  a  considerable  number  of 
different  lesions  ;  most  frequently  the  association  of  this  organism 


250  MANUAL   OF   MEDICINE 

with  the  disease  is  accidental,  but  in  some  cases  it  is  undoubtedly 
pathogenic  and  the  actual  cause  of  the  conditions  found  after  death. 
Aspergillus  fufuigatus  is  the  species  that  is  most  often  parasitic  in 
addition  to  being  saprophytic,  and  this  is  apparently  dependent 
upon  the  fact  that  the  spores  of  this  species  develop  readily  at  the 
body  temperature  of  most  warm  -  blooded  animals.  Aspergillus 
fumigatus  and  A.  flavescens  develop  readily  at  a  temperature  of 
37°  C.  According  to  Lichtheim,  aspergillus  fumigatus  has  a  special 
affinity  for  the  membranous  labyrinth,  but  the  characteristic  lesions 
produced  by  this  fungus  are  also  found  in  such  internal  organs  as 
the  kidneys,  lungs,  Peyer's  patches,  glands,  etc.,  when  the  spores  are 
injected  into  the  circulation  of  animals.  Primary  aspe.rgillar  mycosis 
in  internal  organs  removed  from  direct  access  of  the  air  is,  according 
to  De  Bar)',  of  doubtful  occurrence. 

In  the  human  subject  aspergillar  mycosis  is  most  often  found 
associated  with  otitis  media,  with  a  mycosis  involving  the  nails,  and 
in  an  interesting  form  involving  the  lungs,  and  known  as  pneumo- 
mycosis, usually  as  a  purely  secondary  phenomenon  and  not  as  the 
cause  of  the  lesions.  The  aspergillar  infection  may  occur  in  any 
case  of  chronic  otitis  and  frequently  gives  rise  to  no  symptoms. 
Occasionally  the  fungus  growth  occurs  primarily  on  the  cornea  or 
conjunctiva,  and  here  the  resulting  lesion  is  usually  of  traumatic 
origin;  thus  one  case  is  quoted  where  the  growth  followed  a  blow 
on  the  eye  from  a  falling  pear,  and  in  another  case  from  a  piece  of 
straw  injuring  the  cornea.  An  ulcer  of  the  cornea  may  be  produced 
in  this  way  in  the  human  subject,  and  experimentally  similar  ulcers 
have  been  produced  in  rabbits  by  inoculations  of  the  cornea  with 
aspergillus  fumigatus.  It  has  also  been  found  in  the  nasal  fossae  and 
in  the  antrum.  In  the  lungs  the  parasite  is  usually  saprophytic, 
forming  a  felt-like  membrane  in  cavities  that  owe  their  origin  to 
other  causes,  such  as  tuberculosis  or  bronchiectasis,  but  exceptionally 
it  is  found  in  lungs  presenting  no  such  lesions,  and  in  one  remark- 
able case  no  other  lesion  was  found  except  extreme  emphysema. 
In  this  case,  which  occurred  in  a  young  agricultural  labourer  aged 
twenty-two  and  was  fatal,  there  was  reason  to  believe  that  the  asper- 
gillar growth  might  have  produced  such  alterations  in  the  lungs  as  to 
destroy  their  elasticity  and  to  cause  the  emphysema.  Clinically  the 
case  was  remarkable  owing  to  attacks  of  suffocative  dyspnoea.  Chante- 
messe  and  others  have  described  a  malady  seen  in  France  amongst 
those  rearing  and  feeding  pigeons  which  resembles  chronic  phthisis 
and  is  no  doubt  confounded  with  it ;  the  prognosis,  however,  of  the 
aspergillar  infection  is  not  so  serioiis  as  that  of  the  tuberculous.     It 


MYCOSES  251 

is  known  that  recovery  is  not  uncommon  in  the  experimental 
pneumomycosis  that  can  be  produced  by  the  injection  of  the  spores 
of  aspergillus  fumigatus,  and  it  is  probable  that  similar  recoveries  are 
not  uncommon  in  the  human  subject. 

The  diagnosis  in  the  human  subject  of  aspergillar  pneumo- 
mycosis can  only  be  arrived  at  by  considering  (i)  the  occupation  of 
the  patient,  the  infection  usually  being  dependent  upon  the  habit  of 
chewing  grain,  and  such  grain  may  be  infected  with  the  aspergillus ; 
(2)  the  detection  in  the  sputum  of  the  mycelium,  hyphae  and  spores  ; 
the  spores  can  only  be  identified  by  their  cultivation  and  by  the 
results  seen  to  follow  their  injection  into  animals.  The  pigeon  is  an 
animal  very  susceptible  to  aspergillar  mycosis  and  usually  dies  some 
three  to  four  days  after  the  injection ;  the  rabbit  usually  survives 
longer,  the  average  duration  of  life  being  six  to  eight  days.  In  the 
case  of  the  pigeon  the  characteristic  lesions  are  found  in  the  lungs 
and  respiratory  tract,  also  in  the  air  sacs  and  in  the  hollow  bones  in 
connection  with  the  bronchi.  Aspergillus  (especially  when  injected 
into  the  circulation)  forms  little  white  nodules  resembling  those  seen 
in  tuberculosis,  and  this  has  led  some  pathologists  to  describe  the 
lesions  under  the  general  name  of  pseudo  -  tuberculosis.  In  the 
nodules  the  mycelial  filaments  are  arranged  more  or  less  radially ; 
sometimes  they  assume  a  fan-like  form.  The  mycelium  is  sur- 
rounded by  macrophages  and  each  nodule  lies  embedded  in  a  necrotic 
area  that  merges  into  an  inflammatory  zone.  These  are  well  seen 
when  the  nodules  are  present  in  the  lungs.  The  vessels  are  throm- 
bosed, and,  as  mentioned  above,  the  mycehum  may  be  found  in  the 
lumen  of  the  vessels. 

For  examining  specimens  histologically  for  the  presence  of  this 
fungus,  logwood  is,  according  to  Boyce,  the  most  useful  stain. 

John  Rose  Bradford. 


252  MANUAL   OF   MEDICINE 


TYPHUS    FEVER 

A  highly  contagious  fever,  usually  lasting  about  a  fortnight,  and 
terminating  by  crisis.  It  is  characterised  by  sudden  onset,  often 
severe  nervous  symptoms,  as  delirium  and  stupor,  and  the  presence 
of  a  mottled  measly  rash  appearing  between  the  fourth  and  seventh 
days,  which  often  becomes  petechial. 

The  bacteriology  of  typhus  requires  further  investigation,  and 
the  specific  microbe  of  the  disease  has  not  yet  been  certainly 
determined.  Dubief  describes  a  diplococcus  which  he  terms 
the  Diplococcus  exanthematicus.  Lewaschew,  a  microccus  which 
in  one  stage  of  its  development  is  flagellated,  and  also  forms 
free  filaments  or  spirochsetas :  to  this  organism  he  gives  the 
name  Spiroch(zta  exa?tihematica.  Other  microbes  have  also  been 
described. 

Etiology. — Typhus  is  a  fever  which  spreads  by  direct  con- 
tagion from  the  sick  to  the  healthy,  and  by  means  of  fomites,  i.e. 
articles  which  have  been  in  contact  with  the  patient  and  to  which 
the  poison  adheres.  The  poison  appears  to  be  given  off  in  the 
breath  and  exhaled  from  the  body,  and  where  many  patients  are 
crowded  together  in  ill-ventilated  rooms  it  acquires  intense  viru- 
lence, but  free  ventilation  renders  it  inert,  and  in  a  well-ventilated 
room  very  close  contact  is  necessary  to  contract  the  disease.  The 
corpse  retains  infective  powers  till  decomposition  has  set  in,  and 
the  disease  has  often  been  communicated  to  persons  making  post- 
mortem examinations  or  dissections.  It  is  a  disease  of  temperate 
climates,  and  is  most  prevalent  during  the  cold  season. 

The  predisposing  causes  are  especially  overcrowding  and  desti- 
tution. It  invades  the  overcrowded  districts  of  large  towns,  prisons, 
barracks,  camps,  ships,  besieged  cities,  and  is  especially  prevalent 
in  times  of  war  and  famine.  In  the  last  century  it  was  often 
termed  jail  fever,  and  so  late  as  1893  an  outbreak  took  place  in 
overcrowded  prisons  in  France. 

In  this  country  it  has  for  many  years  past  shown  a  steady  de- 
cline, and  the  same  is  the  case  in  Ireland,  where  it  used  to  cause 
great  ravages.  In  London  it  is  now  rarely  present,  but  it  still 
lingers  in  some  of  the  large  northern  towns. 

Typhus  is  seldom  seen  except  among  the  poor  and  miserable, 
and  those  persons  whose  avocations  bring  them  into  close  contact 


TYPHUS   FEVER  253 

with  them.  In  this  respect  it  offers  a  marked  contrast  to  typhoid 
fever. 

It  attacks  persons  of  all  ages,  but  is  much  less  severe  and  fatal 
in  the  young.  Under  twenty  the  rate  of  mortality  is  very  low,  not 
above  three  or  four  per  cent.  Above  middle  age  more  than  half 
the  persons  attacked  die.  It  occurs  equally  in  both  sexes.  One 
attack  protects  against  a  second,  but  not  invariably. 

Morbid  anatomy. — Typhus  does  not  cause  any  distinctive 
lesions,  so  that  from  a  post-mortem  examination  alone  it  would 
often  be  impossible  to  diagnose  the  disease. 

The  rigor  mortis  is  of  short  duration.  The  skin  presents 
livid  patches  and  petechial  spots.  The  blood  is  dark  and  co- 
agulates imperfectly.  The  muscles  show  Zenker's  degeneration,  as 
in  typhoid.  The  spleen  is  usually,  but  not  always,  enlarged  and 
softened.  The  heart  is  often  softened,  and  the  muscular  fibres 
granular.  There  is  cloudy  swelling  of  the  liver,  kidneys,  and  other 
glandular  organs.  Sometimes  there  is  catarrhal  or  even  mem- 
branous laryngitis.  The  lungs  are  usually  in  a  state  of  hypostatic 
congestion.  There  are  no  characteristic  lesions  of  the  intestinal 
canal,  or  of  the  central  nervous  system. 

Incubation  period. — The  usual  incubation  period  of  typhus 
is  about  twelve  days,  but  much  shorter  periods,  especially  when 
the  poison  has  been  very  concentrated,  have  been  observed,  even 
a  few  hours,  and  it  may  be  as  long  as  twenty-one  days. 

Symptoms  and  course. ^ — The  onset  of  typhus  is  generally 
sudden.  There  are  rigors  or  repeated  attacks  of  chilliness,  frontal 
headache,  which  is  often  very  severe,  pains  in  the  back  and  limbs, 
particularly  in  the  thighs.  Feelings  of  weariness  and  prostration ; 
sometimes,  especially  in  children,  there  is  vomiting.  There  is 
complete  loss  of  appetite  and  much  thirst.  The  tongue  is  large, 
pale,  coated  with  a  white  fur,  which  soon  becomes  yellowish-brown. 
The  face  is  flushed  and  dusky.  The  countenance  dull  and  heavy. 
The  sclerotics  injected,  eyes  watery,  pupils  small.  Pulse  accelerated, 
full  and  soft.  There  are  noises  in  the  ears,  sleep  is  disturbed  by 
bad  dreams.  After  three  or  four  days  there  is  often  slight  delirium 
on  waking.  There  is  rapidly  increasing  muscular  debility,  tremors, 
tottering  gait,  so  that  the  patient  usually  takes  to  his  bed  on  the 
second  or  third  day  of  his  illness.  The  temperature  rises  rapidly, 
and  may  attain  104  the  first  night.  It  usually  reaches  its  maximum 
by  the  fourth  night,  when  it  may  be  106  ;  it  is  of  a  less  remittent 
type  than  in  typhoid,  the  difference  between  the  morning  and 
evening  not    exceeding   one    to    half   a  degree.     The  bowels  are 


254 


MANUAL  OF   MEDICINE 


generally  constipated,  the  urine  scanty,  high  coloured,  of  high 
specific  gravity,  the  urea  and  uric  acid  in  excess,  and  the  chlorides 
diminished  ;  in  the  later  stages  albumin  is  often  present. 

Between  the  fourth  and  seventh  days,  usually  on  the  fourth  or 
fifth,  the  characteristic  eruption  of  typhus  makes  its  appearance.  It 
consists  of  two  elements — a  diffused  dusky  sub-cuticular  mottling, 
and  maculae.  These  consist  at  first  of  slightly  elevated  spots  of 
irregular  shape  and  size  of  a  rose  or  dusky  pink  colour,  which  soon 
gets  darker,  and  in  the  later  stages  of  the  fever  they  often  become 
the  seats  of  haemorrhage,  and  are  converted  into  petechise.     The 

Temperature  Curve  in  a  Case  of  Typhus  Fever. 


F. 

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105° 
104° 
103° 
f02° 
101° 
100° 
99° 
98° 
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Disease 

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combination  of  mottling  and  maculae  gives  the  raph  a  measly 
appearance.  The  spots  usually  come  out  first  on  the  anterior  fold 
of  the  axilla,  and  on  the  sides  of  the  chest  and  abdomen,  thence 
they  spread  over  the  trunk  and  limbs,  but  seldom  appear  on  the 
face.  Sometimes  they  are  first  observed  on  the  backs  of  the  hands, 
where  they  are  commonly  very  abundant.  At  first  they  disappear 
on  pressure,  later  they  are  permanent,  and  persist  till  the  crisis,  and 
do  not,  as  in  typhoid,  come  out  in  successive  crops.  The  rash  is 
always  present,  except  perhaps  in  the  very  mild  cases,  and  its 
amount  is  some  indication  of  the  severity  of  the  attack.  It  is 
usually  much  slighter  and  more  evanescent  in  children. 

About  the  end  of  the  first  week  the  headache  usually  subsides ; 
and  now,  in  severe  cases,  delirium  becomes  a  prominent  symptom. 


TYPHUS   FEVER  255 

Sometimes  it  is  noisy  and  violent ;  the  patient  shouts  and  struggles, 
-will  get  out  of  bed  and  rush  about,  and  may  even  jump  out  of  the 
window.  This  violent  deUrium  is  usually  followed  by  great  depres- 
sion. More  often  the  delirium  is  of  a  quieter  character,  and  consists 
in  an  incoherent  muttering.  Both  forms  are  attended  by  sleepless- 
ness. The  prostration  increases,  the  tongue  becomes  dry  and  brown, 
the  teeth  are  covered  by  sordes,  an  unpleasant  effluvium  is  emitted 
from  the  body,  and  in  the  breath.  The  eruption  becomes  darker, 
and  about  the  eighth  or  tenth  day  petechije  begin  to  appear.  The 
temperature,  except  in  very  severe  cases,  usually  falls  somewhat 
about  the  eighth  day,  and  has  a  lower  range  during  the  second  than 
during  the  first  week.  Towards  the  middle  of  the  second  week  the 
symptoms  of  excitement  are  followed  by  nervous  depression  and 
stupor.  The  prostration  becomes  extreme ;  the  patient  lies  on  his 
back  with  a  tendency  to  sink  down  in  the  bed ;  he  is  deaf,  takes  no 
notice  of  anj-thing,  and  can  with  difficulty  be  roused ;  but  he  is  not 
asleep,  the  eyes  remaining  half  open,  and  he  often  mutters  incoher- 
ently ;  this  state,  when  well  marked,  is  often  termed  coma-vigil ; 
frequently  there  is  subsultus  tendinum  or  floccitatio.  The  pulse  may 
vary  from  100  to  130,  and  is  weak  and  undulating;  the  heart's 
impulse  is  feeble,  and  the  first  sound  diminished  in  intensity.  The 
breathing  is  accelerated  and  shallow,  and  crepitant  rales  are  audible 
over  the  back.  The  urine  is  often  passed  in  the  bed,  or  may  be 
retained  ;  it  frequently  contains  albumin.  Bed-sores  are  liable  to 
form.  The  patient  may  pass  several  hours  or  days  in  this  state ; 
then  if  he  survives,  usually  on  the  fourteenth  day — sometimes  a  day 
or  two  earlier  or  later — a  sudden  improvement  manifests  itself.  The 
temperature  rapidly  falls,  often  4  to  6  degrees  in  the  course  of  a 
single  night ;  he  falls  asleep  and  awakes  free  from  delirium  and 
stupor,  with  his  tongue  moist,  his  skin  perspiring,  and  an  inclination 
for  food,  though  he  is  still  in  a  state  of  great  prostration,  from  which 
he  now  rapidly  recovers.  Sometimes,  though  the  crisis  takes  place, 
and  the  temperature  falls,  the  patient  does  not  rally,  but  sinks  into 
a  state  of  profound  collapse,  and  so  dies,  the  temperature  rising  again 
before  death.  In  other  cases  the  patient  dies  in  a  state  of  coma 
about  the  fourteenth  or  fifteenth  day,  the  temperature  often  rising  to 
a  great  height— 106  or  more — before  death.  In  mild  cases,  where 
the  nervous  symptoms  are  but  slightly  marked,  the  crisis  often  takes 
place  on  the  twelfth  day,  or  earlier.  If  the  fever  continues  after  the 
twenty-first  day,  it  is  always  due  to  the  presence  of  some  complication. 
Varieties  of  typhiis.— Typhus  differs  greatly  in  its  severity, 
and    extreme    forms    have    been    classed    as    varieties.      In  severe 


256  MANUAL   OF    MEDICINE 

epidemics,  especially  in  times  of  war,  in  camps  and  besieged  cities, 
the  disease  may  be  fatal  in  the  course  of  one  or  two  days.  This 
has  been  termed  typhus  sideraas,  or  blasting  typhus.  Very  mild 
cases  are  often  termed  febricula.  Sometimes  the  disease  takes  a 
hcemorrhagic  form. 

Complications  and  sequelae. — Bronchitis,  hypostatic  conges- 
tion of  the  lungs,  and  lobular  pneumonia,  are  frequently  present. 
Sometimes  there  are  embolic  infarcts  from  thrombi  in  the  heart  or 
veins  ;  these  may  soften  down,  or  even  cause  gangrene.  Thrombosis 
of  the  veins  in  the  lower  extremities  is  very  common.  Sometimes 
there  is  a  tendency  to  gangrene  of  the  extremities,  probably  due  to 
arterial  occlusion,  either  by  thrombosis  or  embolism.  Gangrenous 
bed-sores  are  liable  to  form.  Suppurative  parotitis  is  more  common 
than  in  typhoid.  Secondary  abscesses  are  liable  to  form  in  other 
parts. 

Meningitis  is  a  rare  complication,  but  sometimes  occurs  :  and 
typhus  may  be  followed  by  hemiplegia  or  other  forms  of  paralysis, 
probably  the  result  of  embolism  or  thrombosis.  Mania,  melancholia, 
and  dementia  occasionally  supervene,  as  in  typhoid. 

In  pregnancy,  miscarriage  often  takes  place,  but  by  no  means 
invariably ;  if  near  the  full  time,  the  child  is  usually  born  alive, 
and  is  healthy. 

Relapse  in  typhus,  though  not  unknown,  is  of  great  rarity. 

Diagnosis. — Typhus  usually  occurs  in  epidemics,  and  then 
can  generally  be  diagnosed  without  much  difficulty,  but  sporadic 
cases,  and  the  earlier  cases  of  an  outbreak  often  escape  recognition. 
The  only  characteristic  symptom  is  the  eruption,  but  this  may  be 
simulated  by  other  conditions,  or  may  be  only  slightly  marked. 

From  typhoid  the  main  points  of  distinction  are  the  more 
sudden  onset,  the  higher  range  of  temperature  during  the  first  few- 
days,  its  less  remittent  type,  the  dull  heavy  aspect,  the  injected 
sclerotics,  the  contracted  pupils,  the  paler  tongue,  the  absence  of 
abdominal  distension  and  diarrhoea,  the  greater  tendency  to  delirium 
and  stupor.  The  rash  differs  in  its  earlier  appearance  and  the 
accompanying  general  mottling  ;  the  more  extensive  distribution,  the 
darker  colour  and  irregular  size  of  the  maculae,  their  persistence, 
and  their  conversion  into  petechise.  But  nevertheless,  acute  forms 
of  typhoid  with  a  very  abundant  rash  may  be  very  difficult  at  first 
to  distinguish  from  typhus.  Widal's  serum  reaction  does  not  seem 
to  be  a  decisive  criterion,  as  the  serum  in  typhus  appears  to  have 
some  power  in  causing  clumping  of  typhoid  bacilli,  though  it  acts 
more  slowly. 


TYPHUS   FEVER  257 

The  purpuric  spots  which  sometimes  occur  in  ulcerative  endo- 
carditis have  been  mistaken  for  the  typhus  rash.  Rheumatic 
purpura  may  cause  difficulty,  the  severe  pains  in  the  limbs  often 
present  in  typhus  may  likewise  simulate  rheumatism,  but  they  are 
muscular  rather  than  arthritic. 

The  rash  of  measles  has  some  resemblance  to  that  of  typhus, 
but  the  spots  are  larger,  more  raised,  appear  first  on  the  face,  and 
the  other  symptoms  are  different.  Drug  rashes,  as  copaiba,  are 
hardly  likely  to  cause  much  difficulty  if  care  be  taken. 

More  perplexing  are  sometimes  cases  where  tramps  and  vagrants 
are  attacked  by  some  acute  febrile  disease  as  pneumonia  ;  their  skin 
is  often  discoloured  by  dirt  and  neglect,  irritated  by  lice,  and 
studded  with  petechia  due  to  flea  bites.  These,  however,  are 
-smaller  than  the  typhus  petechise,  and  the  minute  puncture  can 
usually  be  distinguished. 

Other  febrile  diseases  accompanied  by  delirium,  stupor,  and 
prostration  may  be  confounded  with  typhus.  Asthenic  forms  of 
pneumonia  and  broncho -pneumonia  have  often  given  rise  to 
confusion  in  both  directions,  the  earlier  causes  of  an  outbreak 
having  on  more  than  one  occasion  been  regarded  as  bronchitis  and 
broncho-pneumonia.  The  presence  of  the  rash  and  the  physical 
signs  must  be  the  criteria. 

During  epidemics,  meningitis,  delirium  tremens,  and  uraemia  are 
liable  to  be  regarded  as  typhus.  Besides  the  absence  of  the  rash 
which  is  the  most  important  distinction,  the  headache  of  meningitis  is 
-more  intense,  of  a  more  darting  character,  accompanied  by  great 
intolerance  of  light  and  sound  (while  in  typhus  the  senses  are 
usually  obtuse),  vomiting  is  more  frequent,  spasmodic  and  paralytic 
affections  of  the  cerebral  nerves  are  more  likely  to  take  place,  and 
the  pulse  is  often  slow.  In  delirium  tremens  the  tongue  is  usually 
moist,  the  skin  often  perspiring,  there  have  been  no  rigors  or  severe 
headache,  and  unless  there  be  some  complication  as  pneumonia  the 
temperature  is  not  much  raised.  Uraemia  may  closely  resemble 
typhus,  the  dry  brown  tongue,  the  stupor,  the  muttering  delirium, 
the  albuminuria  are  common  to  both,  but  in  uraemia  there  is  no 
rash,  and  the  temperature  is  seldom  much  raised. 

Treatment. — Preventive  treatment  requires  the  clearing  out 
and  disinfection  of  overcrowded  houses,  and  the  removal  of  the 
sick  to  well-ventilated  rooms.  All  fomites  should  be  disinfected  by 
baking,  fumigation,  or  steeping  in  disinfecting  solutions.  No  one  but 
the  necessary  attendants  should  be  allowed  access  to  the  patients. 
The   nurses   should,  if  possible,  be   selected   from   those   who   are 

VOL.  I  S 


258  MANUAL  OF  MEDICINE 

rendered  immune  by  a  previous  attack;  where  this  is  impracticable 
they  should  be  as  young  as  possible,  as  the  disease  is  much  milder 
in  the  young.  The  medical  attendant  should  wear  a  special  coat 
or  overwrap  when  visiting  the  cases.  He  should  never  stoop 
down  and  put  his  ear  to  the  patient's  chest,  but  use  a  long  binaural 
stethescope,  and  should  avoid  inhaling  the  air  evolved  when  the 
bed-clothes  are  turned  back. 

It  is  of  the  utmost  importance  that  the  room  should  be 
cool  and  thoroughly  well  ventilated,  not  only  for  the  sake  of  the 
attendants,  but  also  for  the  patient's  own.  In  a  recent  outbreak  of 
typhus  in  a  prison  in  Paris  the  earlier  cases  all  died,  the  remainder 
were  transferred  to  the  garden  and  treated  in  the  open  air,  and  all 
recovered. 

The  general  regimen  and  diet  must  be  the  same  as  that  re- 
commended for  t}'phoid,  but  as  there  are  no  intestinal  lesions  the 
restrictions  need  be  less  severe,  and  solid  food  may  be  given 
as  soon  as  the  appetite  returns.  Alcoholic  stimulants  are 
seldom  required  under  the  age  of  twenty,  in  older  patients  they 
must  be  freely  administered  when  signs  of  nervous  or  cardiac 
prostration  appear.  The  temperature  should  be  kept  down  by 
tepid  bathing,  sponging,  cold  packing,  the  application  of  cold  to 
the  head.  These  measures  will  tend  to  prevent  or  relieve  the 
delirium  and  stupor.  If  there  is  great  sleeplessness,  some  hypnotic 
is  indicated.  It  is  safer  not  to  give  chloral  in  the  later  stages  of 
the  fever  when  the  heart  is  weakened.  Opium  may  be  given  alone, 
or  combined  with  digitalis  ;  Graves  strongly  recommended  a  com- 
bination of  opium  and  antimony ;  tinct.  opii  3i-  ant.  tart.  gr.  iv.  aq. 
camph.  ad.  5  viii.,  a  tablespoonful  every  two  hours  till  sleep  is 
induced.  Where  opium  is  contra-indicated,  as  where  there  is  much 
hypostatic  congestion  of  the  lungs,  belladonna  may  be  given,  or  a 
hypodermic  injection  of  hyoscin,  gr.  2-^. 

When  there  is  much  subsultus  tendinum,  and  floccitatio,  and 
other  signs  of  great  nervous  prostration,  camphor  gr.  iv.  and  musk 
gr.  X.  used  formerly  to  be  given,  and  apparently  with  much  benefit. 
In  collapse,  ether  5ss.  and  liq.  strychn  i  to  3  minims  may  be  injected 
hypodermically.  Hypostatic  congestion  of  the  lungs  and  lobular 
pneumonia  require  free  stimulation,  and  ol.  terebinth,  m.  x.  com- 
bined with  ether  and  ammonia  may  be  administered.  Counter- 
irritation  in  the  form  of  mustard  poultices  or  turpentine  stupes  may 
be  used,  but  the  skin  must  never  be  blistered. 

The  state  of  the  bladder  must  be  carefully  attended  to  ;  bed 
sores   must   be  prevented    by  cleanliness,  the  skin  may  be  washed 


MEASLES  259 

with  a  spirit  lotion,  if  any  redness  appears  it  may  be  painted  with 
flexile  collodion.  A  water  pillow  or  water  mattress  may  be 
employed.  Secondary  suppurations  and  gangrene  must  be  treated 
in  accordance  with  the  rules  of  surgery. 

When  the  patient  is  convalescent  he  should  not  be  allowed  to 
mix  with  other  people  in  the  clothes  he  was  wearing  when  attacked, 
without  their  having  been  thoroughly  disinfected,  though  it  is  best 
to  have  them  destroyed ;  and  he  is  to  be  regarded  as  capable  of 
communicating  the  disease  to  others  for  a  period  of  four  weeks  from 
the  commencement  of  his  illness.  He  himself  should  have  several 
disinfecting  baths.  Neglect  of  these  precautions  has  often  spread 
the  disease. 

W.  Cayley. 


MEASLES 

Syn.   Morbilli 


Measles  is  a  specific  infectious  fever,  characterised  by  catarrhal 
inflammation  of  the  nasal  and  respiratory  mucous  membranes,  and 
the  presence  of  a  distinctive  red  eruption. 

Etiology. — The  disease  is  met  with  pretty  well  all  over  the 
world,  and  is  apparently  independent  of  climate,  being  found  to 
prevail  under  opposite  extremes  of  temperature.  Having  once  ob- 
tained a  footing  in  a  country,  it  never  seems  to  entirely  die  out,  though 
its  prevalence  shows  considerable  seasonal  fluctuation.  In  Great 
Britain  the  seasonal  prevalence  of  measles  is  peculiar,  inasmuch  as 
"the  monthly  curve  shows  a  double  rise,  one  occurring  in  the  spring 
and  early  summer,  and  the  other  in  the  winter,  the  maxima  being 
reached  in  June  and  December  respectively.  Periods  characterised 
by  increased  prevalence  of  measles  have  been  noticed  to  recur 
every  eighteen  months  or  two  years,  and,  according  to  Whitelegge, 
there  are  indications  of  what  may  be  regarded  as  a  major  curve, 
the  maxima  of  which  are  separated  by  intervals  of  about  ten  years. 

Although  the  large  majority  of  attacks  are  mild,  the  disease 
is  liable  to  take  a  severe  form  in  young  children,  especially  under 
the  influence  of  poverty  and  a  defective  hj-giene,  but  no  outbreak 
of  measles  comparable  in  severity  with  the  form  recognised  in  the 
past  by  the  name  "  Black  Measles  "  is  ever  met  with  in  this  country 
at  the  present  day. 


266  MANUAL   OF   MEDICINE 

Infection  in  measles  is  usually  derived  from  personal  contact 
with  a  previous  case.  Indirect  infection  through  the  agency  of 
clothes,  books,  toys,  etc.,  no  doubt  occurs  sometimes,  but  the 
activity  of  the  contagium  is  rapidly  destroyed  by  free  exposure  to 
air  and  light.  The  disease  is  infectious  from  a  very  early  stage, 
even  before  the  initial  symptoms  are  sufficiently  pronounced  to 
lead  to  its  recognition ;  hence  it  is  that  isolation  of  the  patient, 
even  when  practised  early  in  the  attack,  is  so  often  ineffectual  in 
checking  the  spread  of  the  disease.  A  patient  should  be  regarded 
as  probably  infectious  for  at  least  a  fortnight  after  the  appearance 
of  the  rash,  and  should  not  be  allowed  to  mix  with  other  children 
even  then,  should  any  sign  of  catarrh  or  desquamation  be  detected. 
School  attendance  is  without  doubt  the  most  potent  factor  in  the 
propagation  of  the  disease. 

A  distinct  predisposition  is  conferred  by  the  presence  of  any 
catarrhal  condition  of  the  respiratory  passages,  so 'that  rickety 
children,  and  those  of  a  tuberculous  constitution,  are  very  liable  to 
attack ;  and  pre-eminently  those  who  at  the  time  are  suffering  from 
chronic  bronchitis,  whooping-cough,  broncho-pneumonia,  or  actual 
phthisis,  or  who  have  recently  had  an  attack  of  scarlet  fever  or 
diphtheria.  In  countries  not  previously  invaded  by  the  disease  no 
special  liability  is  apparent  in  respect  to  either  age  or  sex.  Second 
attacks  of  measles  occur  not  unfrequently,  but  a  true  relapse  is 
extremely  rare. 

The  incubation  stage  in  most  cases  of  measles  is  about  ten 
days ;  in  other  words,  the  eruption  is  very  likely  to  declare  itself 
on  the  fourteenth  day  after  infection  has  been  received.  In  some 
instances  the  latent  period  appears  to  be  two  or  three  days  longer, 
and  it  may  be  shortened  to  the  same  extent  Sixteen  days  should 
elapse  after  a  child  has  been  exposed  to  infection  before  it  can  be 
regarded  as  free  from  the  suspicion  of  having  taken  measles,  dis- 
infection having  been  carried  out  at  the  commencement  of  the 
quarantine. 

Syoiptoms. — The  invasion  is  characterised  by  the  sudden 
access  of  fever  and  more  or  less  catarrh.  The  temperature  may 
reach  103°  F.  by  the  evening  of  the  first  day,  and  there  is  usually 
loss  of  appetite,  coating  of  the  tongue,  frontal  headache,  and  some- 
times nausea,  though  rarely  actual  vomiting.  The  conjunctivas 
become  injected  and  watery,  and  the  eyelids  probably  red  and 
swollen.  Cough,  often  of  a  croupy  character,  hoarseness,  and 
sneezing  occur,  together  with  a  variable  amount  of  nasal  discharge. 
Diarrhoea  is  liable  to   arise   at   this  stage,   and  is  sometimes  very 


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262  MANUAL   OF   MEDICINE 

intractable,  while  epistaxis  is  not  uncommon.  Lachrymation  and 
photophobia  may  be  very  pronounced,  the  latter  a  source  of  con- 
siderable discomfort,  and  the  face  not  unfrequently  presents  a 
blotchy  or  "  measly  "  appearance,  best  marked  in  the  region  around 
the  mouth  and  nose.  The  aspect  of  a  child  during  the  early 
stage  of  measles  is  frequently  very  characteristic ;  he  looks,  as 
indeed  he  feels,  the  embodiment  of  human  misery. 

Now,  the  condition  described  above  may  persist  throughout 
the  pre-eruptive  stage,  but  more  often  in  benign  attacks  a  distinct 
improvement  sets  in  within  forty-eight  hours  of  invasion,  characterised 
by  a  partial  remission  of  temperature,  and  a  lessening  in  the 
severity  of  the  coryza  and  other  catarrhal  symptoms. 

The  improvement,  however,  is  but  temporary,  for  during  the 
course  of  the  third  or  fourth  day,  usually,  in  some  cases  a  few 
hours  earlier,  the  characteristic  measles  eruption  begins  to  show 
itself,  and  its  development  is  attended  with  an  aggravation  of  both 
the  febrile  and  catarrhal  symptoms.  The  temperature  rises  rapidly 
as  the  eruption  comes  out,  registering,  perhaps,  104°  F.  or  more 
within  twelve  hours.  The  cough,  sneezing,  and  lachrymation 
become  more  pronounced ;  rhonchi  may  be  heard  over  both  lungs, 
and  often  moist  rales  in  addition ;  the  respiratory  rhythm  is 
accelerated.  A  sero-purulent  discharge  runs  from  the  eyes,  and 
the  rhinorrhoea  becomes  thicker  and  more  profuse.  Diarrhoea  is 
apt  to  recur,  or  it  may  now  appear  for  the  first  time,  and  there  is 
sometimes  frequent  desire  to  pass  water,  due,  no  doubt,  to  slight 
urethral  irritation.  There  is  always  some  enlargement  of  the 
lymphatic  glands  in  the  sub-maxillary,  sub-mastoid,  and  cervical 
regions,  but  the  swelling  is  rarely  very  great,  or  attended  with  much 
tenderness.  These  symptoms  commonly  reach  their  full  de\^elop- 
ment  coincidently  with  the  eruption,  and  the  patient  will  in  all 
probability  be  at  his  worst  on  the  fifth  or  sixth  day  of  the  disease. 

In  most  cases  speedy  improvement  then  sets  in,  the  temperature 
being  rarely  sustained  for  much  more  than  thirty-six  hours  after 
the  first  appearance  of  the  rash.  As  a  rule  it  falls  rapidly,  the 
normal  being  reached  in  favourable  attacks  at  some  time  during 
the  sixth  day,  or  by  the  seventh  morning  at  the  latest.  The  drop 
of  temperature  is,  however,  often  incomplete,  but  if  delayed  for 
more  than  a  few  hours,  it  usually  indicates  the  supervention  of 
pulmonary  mischief. 

The  eruption  presents  the  following  characters  : — It  appears 
in  the  form  of  small  red  spots,  usually  first  seen  on  the  sides  of 
the  forehead  and  head  at  the  margin  of  the  hairy  scalp,  and  on  the 


MEASLES  263 

upper  part  of  the  neck  behind  the  ears.  The  spots  soon  spread 
over  the  face,  neck,  trunk,  and  arms,  for  the  most  part  in  a  down- 
ward direction,  and  lastly  invade  the  legs  and  feet,  the  lower 
extremities  being  affected  from  twelve  to  twenty-four  hours  later 
than  the  face.  As  the  rash  develops,  the  individual  spots  become 
larger  and  distinctly  papular.  They  coalesce  with  neighbouring 
ones  in  variable  degree,  and,  as  a  result  of  their  confluence, 
irregular  raised  tracts  of  red  injected  skin  are  presented,  the  in- 
tervening areas  remaining  pale  and  unaffected.  The  spots  are 
often  said  to  show  a  crescentic  grouping,  and  this,  no  doubt,  is 
as  common  an  arrangement  as  any  other  which  the  imagination 
may  suggest.  The  extent  to  which  the  face  is  involved  varies  a 
good  deal ;  in  some  cases  the  spots  are  mainly  confined  to  the 
forehead  and  chin.  The  circumoral  region  frequently  presents  a 
blotchy  appearance,  and  is  more  often  than  not  definitely  invaded 
by  the  eruption.  Both  the  flexor  and  extensor  aspects  of  the 
limbs  are  affected  promiscuously,  and  the  rash  is  usually  repre- 
sented on  the  palms  and  the  soles  by  a  simple  vivid  flush.  It 
may,  however,  in  these  situations,  be  of  a  spotted  character,  but  is 
never  distinctly  raised. 

The  rash  fades  in  the  order  in  which  it  appeared,  and  rarely 
remains  fully  out  for  more  than  twenty-four  hours  at  any  particular 
spot.  It  will  consequently  have  nearly  disappeared  on  the  face  by 
the  time  it  is  reaching  its  full  development  on  the  legs.  The 
actual  eruption  will  usually  have  faded  by  the  end  of  the  week,  but 
a  brown  or  purplish  mottled  staining  can  usually  be  detected  on 
the  trunk  and  legs  for  several  days,  even  a  week  or  more,  after  the 
hypertemia  has  disappeared.  A  fine  scurfy  peeling  usually  follows. 
This  is  rarely  extensive,  sometimes  confined  to  the  trunk ;  in  other 
cases  limited  to  the  face  and  limbs,  but  it  is  never  seen  on  the 
palms  or  soles.  The  peeling  is  usually  completed  within  ten  days 
after  the  rash  has  faded.  It  is  sometimes  stated  that  numerous 
small  red  points  or  spots  with  bluish-white  centres  may  be  detected 
on  the  palate  or  the  inside  of  the  cheek  and  lips  for  some  hours, 
even  three  days  (Koplik),  before  the  eruption  appears  on  the  skin. 
They  can  be  detected  in  some  cases,  but  far  more  frequently 
they  cannot,  and  usually  nothing  more  can  be  made  out  than  a 
catarrhal  redness  of  the  entire  faucial  and  buccal  mucous  mem- 
brane, which  has  existed  since  the  beginning  of  the  illness. 

In  some  attacks  of  measles  the  eruption  is  very  transient  and 
indistinct ;  indeed,  it  may  be  absent  altogether. 

Of  the  severe  forms  of  measles  two  well-recognised  varieties  are 


264  MANUAL  OF  MEDICINE 

met  with,  \\z.  pulmonary  and  toxic.  In  the  former,  grave  pulmonary 
implication  is  present  from  the  outset ;  the  breathing  becomes 
extremely  rapid,  and  the  surface  dusky.  The  temperature  runs  at 
a  high  level,  and  the  pulse  is  very  frequent.  Fine  crepitation  can 
be  detected  all  over  the  lungs  without  obvious  dulness,  dependent 
on  widespread  catarrh  of  the  bronchioles,  and  general  pulmonary 
congestion.  The  rash  is  often  patchy,  or  it  may  be  almost  entirely 
suppressed.  Cyanosis,  drowsiness,  and  coma  supervene,  and  death 
occurs  before  the  week  is  out,  in  young  children  often  preceded  by 
convulsions. 

In  the  toxic  form,  a  typhoid  condition  rapidly  supervenes.  The 
temperature  is  sometimes  as  high  as  106°  F.  ;  the  pulse  becon.es 
extremely  feeble,  often  reaching  180  or  200,  and  the  tongue  dry 
and  brown.  The  rash  is  intense,  and  soon  becomes  petechial ; 
epistaxis  is  common,  and  muscular  tremor  pronounced.  Delirium 
is  present  early,  and  soon  passes  into  stupor,  and  the  patient  dies 
comatose  on  the  fourth  or  fifth  day.  The  variety  known  to  the 
older  writers  as  "black  measles,"  if  not  hsemorrhagic  smallpox, 
must  undoubtedly  have  represented  an  extreme  development  of 
the  toxic  form  of  the  disease. 

Measles  arising  shortly  after  an  attack  of  scarlet  fever  is  often 
characterised  by  a  higher  mortality  and  a  shortening  of  the  pre- 
emptive stage.  The  rash  often  appears  on  the  first,  and  rarely 
later  than  the  second,  day  of  illness.  When  measles  attacks  a 
person  who  is  just  recovering  from  diphtheria,  the  condition  is  very 
serious,  as  there  is  great  danger  of  the  latter  reappearing  in  the 
laryngeal  form.  Membrane  rapidly  spreads  down  into  the  smaller 
bronchi,  and  the  case  usually  proves  fatal ;  broncho-pneumonia  in 
some  degree  being  rarely,  if  ever,  absent. 

The  complications  of  measles  for  the  most  part  represent  an 
exaggeration,  in  some  cases  an  extension,  of  the  catarrhal  condition 
which  is  a  normal  feature  of  the  attack.  The  most  important  are 
undoubtedly  certain  inflammatory  affections  of  the  respiratory 
organs,  viz. — aci/te  lar\-ngitis,  capillar}'  bronchitis,  and  broncho-pneu- 
?no?iia,  the  symptoms  of  which  in  no  way  differ  from  those  of  the 
independent  disorders.  The  laryngitis,  however,  may  be  membran- 
ous, in  which  case  marked  stridor  develops.  In  some  cases  it  is 
undoubtedly  diphtheritic,  while  in  others  it  is  said  to  be  due  to  the 
agency  of  pyogenetic  micro-organisms. 

Catarrhal  stomatitis  may  develop,  attended  with  the  formation 
of  shallow  ulcers  on  the  gums  and  adjacent  side  of  the  tongue  or 
cheeks.     In  ill-nourished,  or  strumous  children,  though  usually  at  a 


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266  MANUAL  OF  MEDICINE 

later  date,  severe  gangrenous,  or  sloughing  stomatitis,  known  as 
canciiin  oris  or  noma,  may  arise  and  lead  to  a  fatal  issue^  perhaps 
a;;tended  with  necrosis  of  the  alveolar  process,  or  even  perforation 
of  the  tissues  of  the  cheek ;  and  the  same  condition  may  affect  the 
vulva  in  female  children.  The  nasal  catarrh  of  measles  may  give 
rise  to  a  chronic  ?tnico-puruktit  rhmorrhcca.  Extension  along  the 
Eustachian  tube  frequently  leads  to  catarrh  of  the  middle  ear, 
characterised  by  deafness,  tinnitus,  and  otalgia.  This  often  be- 
comes purulent,  hence  chrotiic  otitis  media,  perforation  of  the  drum, 
and  troublesome  otorrhoea  are  common.  The  conjunctival  catarrh 
sometimes  leads  lo  phlyctenular  cotijunctivitis,  or  it  may  develop  into 
severe  muco-purulent  ophthalmia,  attended  with  intense  chemosis. 
Keratitis,  or  ulceration  of  the  cornea,  is  liable  to  supervene,  sometimes 
leading  to  hypopyon,  and  even,  in  rare  instances,  to  panophthalmitis. 
Diarrhcea  may  become  excessive,  and  even  prove  fatal  through 
intensity  of  catarrhal  enteritis.  Certain  affections  of  the  nervous 
system  are  occasionally  observed  to  follow  measles  in  children,  of 
which  chorea  and  muscular  atrophy  of  limited  distribution,  suggesting 
anterior  poliomyelitis,  are  perhaps  the  most  common;  while  both 
diffuse  myelitis  and  hemiplci^ia  of  doubtful  origin  have  been  known 
to  arise  during  the  course  of  the  attack.  A  peculiar  form  of  bliftd- 
ness,  unattended  with  any  obvious  lesion  of  the  fundus  or  transparent 
media,  has  sometimes  been  observed  in  adults.  Phthisis,  suppuration 
of  the  7nastoid cells,  and  caries  of  the  petrous  bone  with  its  consequences, 
are  all  conditions  for  which  an  original  attack  of  measles  must  often 
be  held  responsible. 

Bacteriology. — The  specific  infecting  agent  in  measles  is 
doubtless  a  living  microbe,  but  its  identity  has  so  far  not  been  con- 
clusively demonstrated.  Canon  and  Pielicke  in  1892  discovered  a 
small  bacillus  in  the  blood  and  sputum  of  measles  which  they 
succeeded  in  cultivating.  Their  observations,  however,  lack  con- 
firmation, and  it  has  been  supposed  by  some  that  the  bacillus  was 
in  reality  that  of  influenza.  Secondary  invasion  by  septic  and 
pyogenetic  micro-organisms,  however,  is  common,  and  to  their 
presence  most  of  the  fatal  complications  of  the  disease  must  be 
ascribed.  Moreover,  both  diphtheria  and  tubercle  are  liable  to 
supervene  during  early  or  late  convalescence,  in  each  case  showing 
characteristic  lesions. 

The  post-niortem  appearances,  apart  from  its  complications, 
are  inconclusive  in  measles. 

Prognosis. — The  death-rate  in  different  epidemics  of  measles 
is  very  variable.     It  varies  from  two  or  three  to  over  fifty  per  cent 


MEASLES 


267 


in  proportion  to  the  number  of  young  children  amongst  those 
attacked,  their  social  status  and  general  physique,  and  the  coldness 
of  the  season. 

The  influence  of  age  is  well  shown  by  the  following  figures, 
quoted  by  Dr.  Theodore  Thomson,  as  representing  the  fatality  of 
an  epidemic  affecting  an  urban  population  of  35,000  persons, 
amongst  whom  the  compulsory  notification  of  measles  was  in  force. 


Age  in  Years. 

Percentage  Incidence. 

Percentage  Fatality. 

O-I 

7.2] 

9.6) 

1-2 

II. 9 

19.7 

2-3 

17.2 

[13.7  \ 

10.2 

8.5^ 

3-4 

16.2 

4.9 

4-5 

17    J 

^2.8 

i-SJ 

16.1 

S-io           .... 

6.2 

I.I 

10  and  over 

.07) 

0.  J 

Measles  is  most  fatal  during  the  latter  half  of  the  first,  and  the 
second  years  of  life ;  after  this  the  fatality  rapidly  declines  until  the 
fifth  year  is  reached,  when  it  almost  ceases  to  exist.  A  rachitic, 
tuberculous,  or  syphilitic  dyscrasia,  or  the  presence  of  whooping- 
cough,  diphtheria,  or  chronic  lung  disease,  implies  a  high  fatality. 

Special  symptoms  which  point  to  an  unfavourable  prognosis  are, 
early  high  temperature  without  remission,  early  rapidity  of  breath- 
ing, cyanosis,  rapid  and  feeble  pulse,  dry  brown  tongue,  petechial 
eruption,  severe  diarrhoea,  muscular  tremor,  stupor,  and  convulsions  ; 
while  the  supervention  of  any  complication,  such  as  membranous 
laryngitis,  capillary  bronchitis,  broncho-pneumonia,  or  noma,  is 
equally  serious. 

Diagnosis. — Measles,  if  unattended  with  a  rash,  may  be 
difficult  to  distinguish  from  a  simple  cold  in  the  head  and  chest, 
but  such  peculiarity  of  the  attack  is  by  no  means  common.  The 
pyrexia  of  measles  is  usually  more  pronounced,  and  it  may  be 
possible  to  establish  a  connection  with  an  undoubted  attack.  Only 
three  of  the  eruptive  fevers  are  likely  to  be  mistaken  for  measles, 
viz. — rotheln,  scarlet  fever,  and  early  smallpox. 

From  rotheln  the  distinction  may  be  very  difficult.  Apart  from 
any  connection  with  a  previous  case,  the  following  points  are  of 
value  : — In  rotheln,  the  degree  of  pyrexia  and  the  severity  of  the 
catarrhal  signs  are  less.     There  is  an  absence  of  pre-eruptive  ill- 


268  MANUAL   OF   MEDICINE 

ness,  the  rash  being  usually  the  first  sign,  though  tenderness  of  the 
cervical  glands  may  have  been  complained  of  previously.  The 
rotheln  eruption  is  more  transient,  and  presents  features  which  are 
discussed  more  fully  in  the  article  devoted  to  the  description  of 
that  disease  (see  p.  272). 

In  scarlet  fever,  vomiting  is  more  likely  to  be  present  at  the  out- 
set, and  the  rash  appears  within  twenty-four  hours  of  invasion. 
Coryza  and  respiratory  catarrh  are  absent ;  the  fauces  are  definitely 
inflamed,  and  perhaps  actually  ulcerated ;  while  the  glands  under 
the  jaw  are  usually  enlarged  and  tender.  The  eruption  is  re- 
presented on  the  face  by  a  simple  vivid  flush,  the  circumoral  region 
remaining  pale  and  unaffected.  It  never  presents  a  spotted 
character  on  the  palms  or  soles.  The  individual  papules  of  the 
eruption  are  smaller  and  more  closely  aggregated,  and  though  the 
papular  element  in  parts  may  be  well  developed,  the  general  surface 
of  the  skin  presents  a  well-marked  flush,  which,  as  it  fades,  leaves 
behind  a  uniform  staining  rather  than  an  appearance  of  mottling. 
The  temperature  shows  a  gradual  decline  as  the  eruption  fades, 
instead  of  falling  suddenly  when  the  rash  has  reached  its  full 
development,  as  is  the  rule  in  measles.  The  peeling  of  the  tongue 
is  more  complete,  and  the  desquamation  characteristic ;  moreover, 
the  subsequent  appearance  of  either  adenitis,  arthritis,  albuminuria, 
or  nephritis,  are  confirmatory  of  scarlatina. 

Smallpox  in  its  early  stage  is  sometimes  mistaken  for  measles, 
but  the  occurrence  of  a  rigor,  vomiting,  and  severe  lumbar  pain  at 
the  outset,  the  absence  of  catarrh,  the  appearance  of  the  rash  on 
the  third  day,  attended  with  an  immediate  fall  of  temperature  and 
a  general  improvement,  are  most  distinctive.  Moreover,  in  small 
pox  the  eruption  can  be  felt  in  the  skin  before  it  is  clearly  visible, 
whereas  in  measles  the  spots  are  always  macular  before  they  be- 
come raised  above  the  surface.  Collie  aptly  compared  the  feel  of 
the  measles  rash  to  that  of  velvet,  in  contrast  to  the  sensation  im- 
parted by  that  of  smallpox,  which  he  likened  to  corduroy. 

The  treatment  of  measles  is  for  the  most  part  cornprised  in 
the  endeavour  to  ward  off  its  complications.  The  patient  should 
be  isolated  as  soon  as  possible,  and  placed  in  a  room  of  fair 
capacity  and  easy  of  ventilation.  He  should  be  protected  from 
draught,  and  the  light  should  be  subdued  in  view  of  the  photo- 
phobia, which  is  often  distressing.  The  temperature  of  the  room 
should  not  be  allowed  to  fall  below  60°  F.,  or  rise  above  70° ;  the 
atmosphere  should  be  moistened  with  steam  from  a  bronchiis 
kettle,  and  the  patient  lightly,  but  warmly,  covered.     If  there  be 


ROTHELN  269 

much  laryngeal  irritation,  a  steam  tent  will  prove  most  soothing,  and 
a  hot  fomentation,  or  sponge  wrung  out  of  hot  water,  may  be 
frequently  applied  over  the  larynx.  In  young  children,  if  there  be 
much  bronchial  affection,  it  is  a  good  plan  to  encase  the  chest  for 
the  first  few  days  in  a  light  jacket-poultice,  which  should  be  changed 
every  four  hours.  Many  a  young  child's  life  has  been  saved  by  this 
means,  and  the  benefit  is  often  very  striking. 

In  toxic  attacks  but  little  can  be  done  beyond  alleviating 
symptoms.  Attempts  to  reduce  the  temperature  by  means  of  cold 
applications,  though  a  source  of  comfort  to  the  patient  by  reason  of 
their  sedative  effect,  have  usually  failed  to  cure.  No  drug  has  been 
proved  to  have  any  influence  on  the  course  of  the  disease.  Rest- 
lessness, insomnia,  and  delirium,  are  indications  for  a  ner\-e  sedative, 
and  either  trional,  chloralamide,  or  the  wet  pack  may  be  used. 
Stimulants  in  small  but  frequent  doses  should  be  given  in  all  really 
severe  attacks,  and  whenever  a  patient  is  taking  his  nourishment 
badly.  The  treatment  of  the  ordinary  complications  of  measles 
calls  for  no  special  mention  here. 

F.   FooRD  Caiger. 


ROTHELN 


Syn    Rubeola,  Rubella,  German  Measles,  Epidemic 
Roseola 

Rotheln  is  'a  specific,  infectious,  and  often  febrile  disorder, 
attended  with  a  morbiUiform  eruption,  enlargement  of  the  lymphatic 
glands  in  the  mastoid  and  posterior  cervical  regions,  and  occasionally 
slight  catarrh  of  the  ocular,  nasal,  and  faucial  mucosa. 

It  is  almost  invariably  a  mild  affection,  and  seems  to  be 
unattended  with  any  recognised  complications  or  sequelae.  It 
occurs  for  the  most  part  in  temperate  climates,  and  appears  to  be 
more  common  in  Europe  and  North  America  than  elsewhere.  In 
our  own  country  it  is  most  prevalent  in  the  spring  and  early  summer, 
especially  the  months  of  April,  May,  and  June.  The  disease  in  this 
country  rarely  shows  the  widespread  epidemic  prevalence  which  is 
so  characteristic  of  measles,  but  commonly  occurs  in  localised 
outbreaks,  for  the  most  part  confined  to  the  members  of  small 
communities,  who   are   thrown   into   intimate  association  by  reason 


2  70  MANUAL  OF  MEDICINE 

of  various  educational,  trade,  or  administrative  necessities.  Tliis 
probably  depends  upon  the  fact  that  the  activity  of  the  contagium 
is  easily  destroyed,  and  that  close  personal  contact,  under  favourable 
conditions,  is  essential  to  effective  extension. 

Apparently  no  special  susceptibility  attaches  to  early  youth ; 
hence  it  is  that  outbreaks  are  no  more  common  in  schools  than 
they  are  amongst  the  adult  employes  of  Government  departments, 
business  houses,  banks,  workshops,  clubs,  and  hotels,  many  of  whom 
probably  have  never  previously  suffered  from  the  disease.  The 
presence  of,  or  recent  convalescence  from,  any  acute  disorder,  such 
as  scarlet  fever,  measles,  or  diphtheria,  undoubtedly  favours  success- 
ful infection,  whereas  the  fact  of  having  once  suffered  from  rotheln 
will  almost  surely  protect  from  subsequent  attack. 

Much  uncertainty  has  existed  in  the  past  as  to  the  nature  of 
rotheln.  It  has  been  variously  held  to  be  a  modified  form  of 
measles,  of  scarlet  fever — a  hybrid  of  both — and  a  separate  and 
specific  infection.  No  other  view  but  the  latter  is  now  tenable, 
and  further  discussion  is  uncalled  for.  It  is  unfortunate  that  greater 
unanimity  has  not  prevailed  in  the  past  amongst  those  to  whom  we 
are  indebted  for  its  clinical  description.  It  is  evident  that  the 
descriptions  given  by  Patterson  in  1840,  and  the  older  German 
writers,  apply,  not  to  rotheln  as  we  know  it  to-day,  but  apparently 
to  a  severe  form  of  measles.  Its  features,  however,  are  now  pretty 
generally  recognised. 

The  incubation  stage  may  vary  from  seven  or  eight  days  to 
fourteen  or  fifteen,  and,  it  is  stated,  even  to  twenty-two.  In  the 
writer's  experience  it  has  been  most  often  ten  days  or  a  little  over. 
In  schools  a  quarantine  of  at  least  twenty  days  after  removal  of  the 
last  case  is  commonly  insisted  on. 

Symptoms. — The  attack  usually  commences  with  a  feeling  of 
malaise,  and  perhaps  slight  febrilicy,  followed  in  a  few  hours  by  the 
appearance  of  the  eruption.  The  rash,  however,  is  often  the  first 
sign.  The  conjunctivae  are  usually  injected,  and  this  may  be  the 
only  evidence  of  catarrh ;  but  more  often  the  patient  experiences 
the  sensation  of  having  a  cold  in  the  head,  which  at  the  same  time 
may  ache,  and  there  may  be  slight  cough,  and  more  or  less  faucial 
discomfort.  On  examination  of  the  throat,  it  is  usually  seen  to  be 
somewhat  reddened  and  injected,  and  the  tongue  moderately 
coated.  The  glands  beneath  the  jaw  are  rarely  much  enlarged, 
but  those  in  the  posterior  cervical  region,  and  the  one  lying  over 
the  mastoid  bone,  are  both  swollen  and  tender.  In  some  attacks 
.  tenderness  of  the  concatenate  glands  is  complained  of  for  several 


ROTHELN  271 

days  before  the  rash  comes  out,  and,  in  rare  instances,  those  in  the 
axillae  and  groins  are  also  involved.  The  temperature  at  the  out- 
set may  rise  to  loi'',  or  even  a  degree  or  two  higher.  It  soon 
reaches  its  climax,  and  falls  to  normal  again  within  forty-eight 
hours.  In  exceptional  cases,  particularly  when  there  is  much 
glandular  affection,  pyrexia  of  greater  degree  and  persistence  may 
be  observed.  Frequently,  however,  the  temperature  remains 
normal  throughout  the  attack  ;  and  this  occurs  more  often  than  is 
usually  credited. 

The  eruption  commonly  appears  first  on  the  face  in  the  form  of 
small  round  or  oval  pinkish-red  spots,  and  from  thence  spreads 
rapidly  over  the  trunk  and  limbs,  and  finally  invades  the  legs. 
The  spots  are  but  slightly  raised,  and  soon  coalesce ;  so  that  a 
uniform  redness  closely  simulating  the  rash  of  scarlet  fever  is 
frequently  to  be  seen  on  the  lower  part  of  the  trunk,  forearms,  and 
Lgs.  An  occasional  result  of  their  coalescence  is  that  irregular 
erythematous  patches  of  variable  extent  and  well-defined  margin 
are  presented.  On  the  face  the  spots  fade  rapidly,  as  a  rule,  with- 
out previous  coalescence  ;  they  are  rarely  very  distinct  for  more  than 
twenty-four  hours,  and  the  circumoral  pallor  may  not  have  been 
encroached  upon.  In  some  instances  the  rash  first  appears  on  the 
trunk  or  limbs,  in  which  case  the  face  probably  escapes  altogether. 
The  rash  commonly  fades  within  three,  or  at  the  most  four  days, 
leaving  little  or  no  staining  behind,  though  definite  peeling  often 
follows.  It  is  usually  of  a  powdery  or  furfuraceous  character,  but 
"pinhole  "  peeling,  indistinguishable  from  that  of  scarlet  fever,  some- 
times, though  very  rarely,  follows  an  undoubted  attack  of  rotheln. 
The  illness  may  be  regarded  as  at  an  end  when  the  rash  has  faded, 
and  in  many  cases  the  patient  cannot  be  said  to  have  been  ill  at 
all.  According  to  Forchheimer,  a  number  of  rose-red  spots  may 
often  be  seen  coincidently  with  the  appearance  of  the  skin 
eruption  on  the  mucous  membrane  of  the  uvula  and  soft  palate. 
They  are  said  to  be  about  the  size  of  a  large  pin's  head,  very  little 
raised  above  the  surface,  devoid  of  crescentic  grouping,  and  not  to 
remain  visible  longer  than  twenty-four  hours. 

Pathology. — As  to  the  nature  of  rotheln  infection  we  know 
nothing,  but  infer  that  it  is  dependent  upon  the  activity  of  some 
specific  micro-organism.  It  is  doubtful  whether  the  disease  is  ever 
directly  fatal ;  nor  are  any  morbid  changes  in  the  blood,  tissues,  or 
internal  organs  recognised.  The  patient  should  be  regarded  as 
probably  infectious  for  at  least  ten  days  after  the  appearance  of  the 
rash,  and  even  longer,  should  any  peeling  remain.     The  occurrence 


272  MANUAL  OF  MEDICINE 

of  a  definite  relapse  has  been  occasionally  recorded ;  but  this,  like 
a  second  attack,  must  be  very  uncommon. 

The  diagnosis  of  rotheln  is  often  confused  by  reason  of  its 
likeness  to  mild  attacks  both  of  scarlet  fever  and  measles. 

It  resembles  mild  scarlet  fever  in  that  slight  faucial  affection  is 
often  present ;  that  the  rash  appears  early  in  the  attack,  and  is 
usually  followed  by  distinct  desquamation.  The  resemblance  is 
most  marked  at  that  stage  when  the  rash  has  faded  from  the  face, 
and  is  present  as  a  continuous  flush  on  the  trunk  and  limbs,  with 
perhaps  a  distinct  remnant  of  papulation.  It  differs  from  scarlet 
fever  in  that  prodromal  vomiting  is  rarely,  if  ever,  present ;  faucial 
injection  is  less  constant,  and  early  cleaning  of  the  tongue,  much 
less  a  raw  tongue,  is  wanting.  The  rash  occurs  on  the  face  in  the 
form  of  slightly  raised  spots,  instead  of  being  represented  by  a 
continuous  vivid  flush,  which  in  scarlet  fever  neither  presents  a 
macular  appearance,  nor  invades  the  oral  circle.  If  seen  at  an 
early  stage,  the  morbilUform  character  of  the  rotheln  eruption  will 
be  apparent  on  the  trunk.  A  complaint  from  the  patient  of  tender- 
ness, or  pain  in  connection  with  the  posterior  cervical  glands  is 
most  characteristic  of  rotheln ;  while  the  absence  of  "  pin-hole " 
peeling,  arthritis,  nephritis,  and  adenitis  during  subsequent  con- 
valescence is  confirmatory  as  far  as  it  goes. 

The  resemblance  between  a  case  of  rotheln  and  a  mild  attack 
of  measles  may  be  so  close  as  to  make  a  confident  diagnosis  in  an 
isolated  case  impossible.  This  is  especially  true  when  the  patient 
has  recently  had  scarlet  fever,  as  under  these  circumstances  the 
pre-eruptive  stage  of  measles  is  frequently  curtailed,  and  con- 
sequently a  valuable  distinction  is  lost.  The  differences  between 
measles  and  rotheln  are  of  degree  rather  than  of  kind ;  hence  the 
difificulty  which  may  be  encountered  in  their  diagnosis.  In  rotheln, 
the  interval  between  exposure  to  infection  and  the  appearance  of 
the  rash  is  more  often  nearer  ten  days  than  fourteen,  and  the 
eruption  appears  on  the  first  or  second  day  of  invasion,  rather  than 
the  third  or  fourth.  The  individual  spots  of  the  eruption  are 
usually  smaller,  pinker,  more  discrete  (while  still  raised),  less  con- 
stant on  the  face,  less  persistent,  and  less  staining,  though  liable  to 
be  followed  by  considerably  more  peeling. 

The  catarrhal  symptoms,  moreover,  are  less  prominent,  if  not 
entirely  absent ;  while  distinct  tenderness  of  the  posterior  cervical 
glands  is  the  rule  rather  than  the  exception. 

An  attack  of  rotheln  calls  for  no  special  treatment.  The 
patient,  if  a  child,  should  be  kept  indoors,  and  not  allowed  to  mix 


ROTHELN  273 

with  others  until  at  least  a  week  or  ten  days  has  elapsed  since 
the  eruption  faded.  The  desquamation  may  be  hastened  by  the 
employment  of  warm  baths  and  vigorous  friction. 

Although  the  vast  majority  of  attacks  are  exceedingly  mild,  the 
possibility  of  rotheln  taking  a  severe  form  must  not  be  lost  sight  of. 
An  outbreak,  occurring  in  1879,  has  been  reported  by  Dr.  Cheadle, 
the  earlier  cases  of  which  were  characterised  by  a  severity  surpass- 
ing that  of  ordinary  measles.  The  attacks  were  mainly  distin- 
guished by  severe  affection  of  the  broncho-laryngeal  tract,  giving 
rise  to  incessant  croupy  cough  of  a  painful  and  harrassing  nature, 
and  by  dusky  red  infiltrations  of  the  faucial  structures.  Coryza, 
lachrymation,  and  intestinal  irritation  were  practically  absent,  but 
excepting  that  the  pre-eruptive  stage  was  unduly  short,  the  attacks 
bore  in  other  respects  more  resemblance  to  severe  measles.  The 
writer  met  with  similar  cases  in  the  year  1888,  the  diagnosis  of 
which  was  most  confusing.  They  occurred  amongst  a  number  of 
children  convalescent  from  scarlet  fever,  and  in  some  instances  the 
attack  proved  fatal. 

The  term  "  epidemic,"  or  "infective  roseola,"  is  applied  by  the 
Council  of  the  ]\Iedical  Officers  of  Schools  Association  to  certain 
cases  which  they  regard  as  entirely  distinct  from  rotheln,  though 
commonly  confused  with  it.  The  cases  occur  in  groups,  usually 
in  the  summer  time,  and  are  characterised  by  absence  of  any  pro- 
dromal symptoms,  and  of  definite  evidence  of  catarrh.  The  rash 
appears  suddenly  on  the  neck,  limbs  and  trunk,  the  face  usually 
escaping  altogether.  It  consists  of  large  rounded  areas  of  bright 
red,  closely  aggregated  spots,  scarcely  raised  above  the  surface  of 
the  flushed  skin.  There  is  an  absence  of  glandular  swelUng,  little 
or  no  pyrexia,  and  the  general  health  is  hardly,  if  at  all,  interfered 
with.  Whatever  view  may  be  taken  as  to  the  nature  of  these  cases, 
they  certainly  sometimes  occur  in  association  with  undoubted 
attacks  of  rotheln. 

F.  FooRD  Caiger. 


VOL.  I 


2  74  MANUAL  OF  MEDICINE 


SCARLET    FEVER 

Syn.  Scarlatina 

Scarlet  fever  is  an  infectious  febrile  disease,  of  which  the  most 
prominent  features  are  inflammation  of  the  faucial  structures,  a  red 
punctiform  rash,  followed  by  characteristic  desquamation,  and  a 
subsequent  tendency  to  inflammatory  affections  of  the  middle  ear, 
glands  in  the  neck,  joints,  and  kidneys. 

Though  showing  a  wide  geographical  distribution,  the  disease 
occurs  but  little  in  tropical  regions.  It  is  a  good  deal  more 
prevalent  in  Europe,  especially  its  north-western  portion,  and  in 
America,  than  other  parts  of  the  world.  Scarlet  fever  is  rarely 
altogether  absent  from  the  larger  towns  of  Western  Europe,  though 
periods  characterised  by  its  wider  extension  throughout  the  country 
at  large  tend  to  recur  at  irregular  intervals ;  and  in  many  of  the 
large  towns  of  Great  Britain  something  approaching  a  local  cycle  is 
often  apparent,  the  periods  of  greater  incidence  recurring  every 
five  or  six  years.  In  this  country  scarlet  fever  is  most  prevalent 
during  the  autumn  and  early  winter  months,  the  maximum  occur- 
ring towards  the  end  of  October  or  beginning  of  November.  It  is 
least  so  during  the  spring  and  summer,  the  minimum  usually  being 
reached  in  either  March  or  April.  The  fatality  has  shown  a  •  pro- 
gressive diminution,  at  any  rate  in  London,  during  the  last  fifteen 
years. 

Etiology. — Infection  is  always  derived  from  a  previous  case, 
either  directly  from  the  patient,  or  indirectly  through  some  article 
of  clothing  or  furniture,  or  perhaps  a  book  or  toy  which  has  become 
contaminated  with  a  minute  particle  of  mucus,  or  of  cuticle  derived 
from  his  person.  The  degree  of  infectivity  attaching  to  the  faucial 
mucus,  and  particularly  to  any  discharge  from  the  nose  or  ear 
which  has  been  present  during  the  scarlatinal  attack,  is  probably 
much  greater  than  that  of  the  desquamating  cuticle,  excepting, 
perhaps,  that  shed  during  the  early  period  of  convalesence.  The 
epidermis,  which  separates  during  the  later  weeks,  is  apparently 
little,  if  at  all,  infectious,  though  the  popular  belief  is  to  the 
contrary.  Scarlet  fever  is  sometimes  conveyed  by  milk,  many 
localised  outbreaks  having  been  definitely  traced  to  a  particular 
dairy.      In  no  case  has  it  been  satisfactorily  estabUshed  that  scarlet 


SCARLET  FEVER 


275 


fever  has  been  propagated  by  means  of  defective  drainage  or  an 
infected  water  supply.  Infection  is  not  very  active  before  the  rash 
is  well  out.  The  patient  is  probably  most  infectious  at  the  height 
of  the  attack,  and  during  the  defervescence.  Infectivity  rapidly 
diminishes  as  convalescence  proceeds,  but  the  time  at  which  a 
person  actually  ceases  to  be  infectious  is  unknown.  He  should, 
however,  be  regarded  as  a  probable  source  of  danger  so  long  as  any 
discharge  from  a  mucous  surface  remains,  and  as  a  possible  source 
until  his  peeling  is  completed.  The  Medical  Officers  of  Schools 
Association  advise  that  isolation  should  be  maintained  for  "  not  less 
than  six  weeks  from  the  date  of  the  appearance  of  the  rash,  provided 
convalescence  is  completed  and  desquamation  has  ceased,  and 
there  is  no  sore  throat,  discharge  from  ear,  suppurating  glands,  or 
eczematous  patches." 

The  following  table  comprises  81,605  consecutive  cases  of 
scarlet  fever  admitted  into  the  hospitals  of  the  Metropolitan  Asylums 
Board  during  the  six  years  ending  1897  : — 


Ages. 

Males. 

Females 

T.,TAL. 

Admitted. 

Died. 

Mortality 
per  cent. 

Admitted. 

Died. 

Mortality 
per  cent. 

.•Admitted. 

T^-    ,        Mortality 

1 

Under  i  .     . 

443 

no 

24.8 

362 

98 

27.1 

805 

208 

25.8 

I  to  2 

1,456 

298 

20.5 

1,371 

280 

20.4 

2,827 

578 

20.4 

2  „    3 

2,631 

406 

15.4 

2,553 

3«3 

15.0 

5,184 

789 

15.2 

3  „    4 

3,599 

404 

II. 2 

3,688 

417 

II-3 

7,287 

821 

"•3 

4  „   5 

3,862 

314 

8.1 

4,140 

281 

6.8 

8,002 

595 

7-4 

i  Totals  under) 
S  years     / 

1 

11,991 

1.532 

12.8 

12,114 

1,459 

12.0 

24,105 

2,991 

12.4 

5  to  10  .     . 

iS>79i 

495 

3-1 

17,592 

523 

3-0 

33,383 

1,018 

3-0 

10  ,,  15 

7,359 

97 

1-3 

7,862 

«5 

I.I 

15,221 

182 

1.2 

15  ,,  20 

2,366 

36 

1-5 

2,368 

35 

r-S 

4,734 

71 

1-5 

20  ,,  25 

926 

II 

1.2 

1,149 

20 

1-7 

2,075 

31 

1-5 

25  ,>  30 

420 

5 

1.2 

657 

7 

I.I 

1,077 

12 

I.I 

30  „  35 

215 

6 

2.8 

343 

6 

1-7 

558 

12 

2.2 

35  „  40 

91 

2 

2.2 

140 

3 

2.1 

231 

5 

2.2 

40  „  45 

45 

4 

f 

80 

3 

125 

7 

45  „  50 

26 

2 

23 

I 

49 

3 

50  „  55 

17 

I 

^  7-4  - 

17 

r  3-1  ^ 

34 

I 

[    5-0 

55  ,.  60 

5 

4 

9 

And  upwards 

I 

J            I 

3 

J       [ 

4 

...  J 

Grand  Totals 

39,253 

2,191 

5.6 

42,352 

2,142 

5-1 

81,605 

4>333          5-3 

2  76  MANUAL   OF   MEDICINE 

The  varying  liability  in  respect  to  age  is  apparent.  The  largest 
number  of  attacks  occurred  in  the  second  quinquennium  of  life,  the 
first  coming  next,  and  then  the  third.  After  fifteen  years  of  age 
the  attacks  were  relatively  few.  All  statistical  records  tend  to  show 
that  the  highest  susceptibility  to  scarlet  fever  occurs  during  the  fifth 
year  of  life. 

The  table  further  shows  that  females  were  attacked  more  often 
than  males  in  the  proportion  of  about  fourteen  to  thirteen. 

A  definite  second  attack  is  occasionally  met  with,  as  is  an  un- 
doubted relapse ;  but  in  most  persons  one  attack  of  scarlet  fever  is 
sufficient  to  protect  for  life. 

The  period  of  incubation  is  usually  three  days,  or  a  little  less. 
It  is  said  that  it  may  be  as  short  as  twenty-four  hours,  and  it  is 
occasionally  as  long  as  six  days.  The  Medical  Officers  of  Schools 
Association  recommends  a  quarantine  of  ten  days  subsequent  to 
removal  of  the  source  of  infection. 

Clinical  description. — From  the  clinical  standpoint  three 
varieties  of  scarlet  fever  are  recognised,  viz.  the  simple,  the  septic, 
and  the  toxic. 

I.  Simple  form,  or  scarlati.ya  benign  a. — The  invasion  is 
commonly  more  or  less  sudden.  The  patient  complains  of  head- 
ache, shivering,  and  aching  pains  in  the  back  and  limbs ;  the  throat 
feels  sore,  and  the  act  of  swallowing  is  uncomfortable,  if  not  actually 
painful ;  the  tongue  becomes  coated  and  the  appetite  lost,  and  in 
most  cases  is  attended  with  troublesome  nausea,  if  not  with  actual 
vomiting.  The  association  of  headache,  vomiting,  and  sore  throat 
is  most  distinctive  of  the  early  stage  of  scarlet  fever.  On  examina- 
tion, the  whole  of  the  faucial  mucous  membrane  is  seen  to  be  red 
and  tumid,  and  the  tonsils  swollen — perhaps  considerably.  The 
temperature  often  registers  102°  F.  by  the  end  of  the  first  day,  and 
the  pulse  is  very  rapid.  The  glands  beneath  the  jaw  are  slightly 
enlarged,  and  probably  somewhat  tender.  The  rash  usually  appears 
within  twenty-four  hours  of  invasion,  and  is  rarely  delayed  more 
than  thirty- six.  It  comes  out  first  on  the  chest,  neck,  and  upper 
arms ;  and  from  thence  spreads  all  over  the  surface  in  the  course  of 
the  next  twenty-four  hours,  for  the  most  part  in  a  downward 
direction.  By  this  time  the  sides  and  tip  of  the  tongue  will  have 
become  red  and  raw-looking  as  the  result  of  incipient  denudation. 
Delirium  of  a  quiet  kind  is  not  unfrequently  met  with  in  children, 
and  is  always  associated  with  a  high  temperature.  Together  with 
the  development  of  the  eruption,  both  the  faucial  and  glandular 
swelling  and  the  general  febrile  signs  increase,  and  the  climax  of 


SCARLET   FEVER  277 

the  attack  is  reached  usually  on  the  third  or  fourth  night  of 
illness. 

A  gradual  improvement  in  all  respects  then  sets  in.  The 
temperature  slowly  declines,  the  faucial  tension  abates,  swallowing 
becomes  less  painful,  the  rash  fades,  and  commencing  desquamation 
becomes  apparent.  The  duration  of  the  febrile  stage  of  simple 
scarlet  fever,  then,  is  about  a  week,  though  often  a  day  or  two  less. 
The  appetite  is  quickly  regained  as  the  throat  improves,  and  con- 
valescence proceeds  rapidly. 

In  some  undoubted  attacks  of  scarlet  fever  there  is  practically 
no  throat  affection  whatever,  though  the  eruption  may  be  extremely 
well  developed ;  the  temperature  is  but  little  raised,  and  the  whole 
attack  may  be  over  within  three  days.  This  is  characteristic  of 
the  cases  often  spoken  of  as  "Surgical  Scarlet  Fever,"  which, 
though  very  mild,  are  certainly  infectious. 

The  scarlatinal  rash  is  of  a  bright  brick-red  colour,  and  consists 
of  two  distinct  elements,  viz.  an  erythematous  flush  and  a  number 
of  minute,  closely-set,  injected  papules,  which,  to  a  large  extent, 
though  by  no  means  necessarily,  correspond  with  the  points  of 
emergence  of  the  hairs.  The  rash,  consequently,  has  a  distinctly 
punctate  appearance.  This  will  be  more  apparent  in  proportion  as 
the  erythematous  element  is  wanting,  and  as  the  latter  fades  before 
the  papular  injection  subsides,  the  punctiform  character  of  the  rash 
is  usually  best  marked  during  the  later  stage.  The  eruption  appears 
first  on  the  chest,  neck,  and  upper  arms,  and,  spreading  downwards, 
reaches  the  legs  some  hours  later.  It  attains  its  full  development 
in  about  two  days, — that  is,  about  the  third  evening  of  the  disease, — 
from  which  time,  or  a  day  later,  it  begins  to  decline,  and,  fading  in 
the  order  in  which  it  came,  is  usually  gone  by  the  end  of  the 
week. 

After  the  rash  has  disappeared  a  uniform  greenish-yellow  stain- 
ing of  the  skin  is  left,  best  marked  on  the  abdomen.  This  is  in 
no  sense  a  mottling.  Where  the  skin  is  normally  harsh,  as  on  the 
outer  side  of  the  legs  and  upper  arms,  a  number  of  coarse  injected 
papules  commonly  remain  for  several  days  after  the  general  eruption 
has  faded.  Occasionally  some  of  the  papules  on  the  trunk  and  arms 
become  distinctly  vesicular,  especially  if  the  rash  be  intense  and 
the  patient  have  been  sweating. 

On  the  palms  and  soles  nothing  but  a  vivid  flush  is  seen, 
punctation  being  exceedingly  rare.  Nor  does  punctation  occur  on 
the  face ;  there  the  rash  is  represented  by  a  red  flush,  which, 
though  present  to  a  slight  extent  on  the  forehead,  nose,  and  chin, 


2  78  MANUAL  OF   MEDICINE 

is  most  intense  on  the  cheeks.  It  never  invades  the  region  around 
the  mouth,  which  ahvays  remains  pale  and  uninjected.  This 
"circumoral  pallor,"  which  is  strictly  limited  by  the  naso-labial 
folds,  stands  out  in  striking  contrast  to  the  vividly  injected  cheeks. 
It  is  an  appearance  seen  in  other  febrile  conditions  besides  the 
early  stage  of  scarlet  fever,  notably  in  pneumonia ;  but  at  a  later 
stage,  viz.  the  second  or  third  day  of  the  rash,  a  fine  powdering 
becomes  apparent  on  the  flushed  surface,  imparting  a  curious 
"  powder  and  rouge  "  appearance  to  the  complexion  which  is  most 
distinctive  of  scarlet  fever.  In  children  of  delicate  complexion  it 
closely  resembles  the  bloom  on  a  ripe  peach,  and  is  most  becoming. 
The  powdering  is  in  reality  the  expression  of  incipient  desquamation. 

More  or  less  peeling  of  the  skin  probably  always  occurs  in  cases 
which  have  been  attended  with  a  definite  rash,  its  amount  being 
generally  proportionate  to  the  intensity  and  persistence  of  the 
latter.  In  infants  in  whom  the  skin  is  velvety  and  contains  a  good 
deal  of  fat,  peeling  is  usually  slight  and  transient,  and  in  adults  is 
sometimes  so  insignificant  as  to  be  practically  limited  to  the  hands 
and  feet.  This  is  especially  true  of  persons  whose  skin  is  naturally 
greasy,  as  in  the  subjects  of  acne  punctata. 

The  character  of  the  desquamation  varies  in  different  parts  of 
the  body.  On  the  face,  ears,  and  inner  side  of  the  upper  arms,  at 
any  rate  at  an  early  stage,  it  is  represented  by  a  simple  powdering 
of  the  surface.  On  the  neck,  trunk,  and  limbs  it  takes  the  form  of 
delicate  flakes  or  scales  of  variable  size,  preceded  by  a  pin-hole  or 
worm-eaten  appearance  of  the  cuticle  which  is  very  distinctive. 
Each  "  pin-hole "  is  caused  by  the  mechanical  rupture  of  the 
delicate  epidermal  covering  of  one  of  the  papules  comprising  the 
eruption.  From  each  of  these  centres  peeUng  extends  centrifugally, 
until,  by  fusion  of  their  peripheries,  any  such  ring-like  arrangement 
becomes  unrecognisable.  From  the  palms  and  soles,  where  it  is 
normally  thick,  the  cuticle  is  shed  in  large  patches  or  shreds,  which 
may  be  continuous  with  that  covering  the  fingers  or  toes,  and  so 
lead  to  the  separation  of  an  incomplete  glove  or  golosh.  On  the 
palms  and  soles  before  actual  separation  occurs  the  surface  becomes 
yellowish,  dry,  and  wrinkled,  suggesting  in  its  appearance  and  feel 
a  piece  of  old  parchment.  In  some  cases  a  dry  chalky  condition 
of  the  palms  and  soles  is  all  that  can  be  found  to  represent 
desquamation. 

Desquamation  is  rarely  completed  until  six  or  eight  weeks  from 
the  date  of  the  eruption,  and  occasionally  not  until  the  expiration 
of  three   or   four   months.       The   earliest   sign   of  peelmg,    viz.    the 


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powdering  on  the  face,  can  usually  be  detected  by  the  second  or 
third  day  of  the  rash.  By  the  end  of  the  first  week  peeling  will  be 
well  marked  on  the  face,  neck,  and  upper  part  of  chest.  By  the 
end  of  the  second  it  will  have  become  general.  By  the  end  of  the 
fourth  it  is  often  complete,  with  the  exception  of  the  palms  and 
soles,  which,  especially  the  latter,  often  require  two  or  three  weeks 
longer. 

The  tefiiperature  in  simple  scarlet  fever  rises  rather  rapidly,  and 
usually  reaches  a  climax  on  the  third  or  fourth  night.  Defervescence 
then  occurs  gradually  by  lysis,  and  the  normal  is  reached  in  most 
cases  on  the  sixth  or  seventh  day.  The  temperature  shows  a  daily 
range  of  from  one  to  two  degrees,  and  the  highest  record  is  rarely 
above  105'. 

The  scarlatinal  pulse  is  characterised  by  undue  rapidity  in 
proportion  to  the  degree  of  pyrexia.  This,  however,  is  only 
observed  during  the  early  stage  of  the  attack.  A  pulse-rate  of  144 
to  160  in  a  child  during  the  first  two  days  of  scarlet  fever  is  in 
itself  no  cause  for  alarm. 

In  some  attacks  there  is  hardly  any  actual  swelling  of  the  ionsils, 
although  they  are  usually  somewhat  red  and  tumid.  In  other  cases  the 
swelling  is  considerable,  and  if  the  inflammation  be  ver}'  acute  their 
surface  may  become  coated  with  granular  fibrinous  deposit,  which  is 
often  mistaken  for  a  diphtheritic  exudation.  Tonsillitis  must,  there- 
fore, be  regarded  as  a  contingent,  rather  than  a  necessary  factor  in 
simple  scarlet  fever,  though  an  essential  feature  in  the  septic  form 
of  the  disease. 

The  appearance  of  the  toftgue  in  scarlet  fever  is  most  distinctive. 
It  rapidly  becomes  coated  with  a  thick  white  fur,  through  which 
some  of  the  fungiform  papillae  may  usually  be  seen  protruding. 
Denudation  of  the  surface  then  begins,  starting  from  the  tip  and 
edges,  which  are  usually  clean  by  the  end  of  the  second  day,  and, 
proceeding  centripetally,  the  whole  surface  of  the  tongue  becomes 
stripped  of  fur  by  the  third  or  fourth  day  of  attack.  The  tongue 
thus  comes  to  present  the  raw  denuded  appearance  w-hich  has  been 
aptly  compared  to  that  of  a  ripe  strawberr5\  Early  in  the  course 
of  the  second  week  a  renewal  of  its  normal  epithelium  takes 
place,  and  the  tongue  resumes  its  usual  aspect.  The  complete- 
ness with  which  the  tongue  peels  is  proportionate  to  the  intensity 
of  the  prcNious  inflammatory  injection  of  the  mucous  lining  of  the 
mouth  and  fauces,  just  in  the  same  way  as  the  amount  of  peeling 
of  the  skin  is  regulated  by  the  intensity  and  persistence  of  the  ante- 
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282  MANUAL  OF   MEDICINE 

II.  Septic  form,  or  scarlatina  ulcerosa. — In  this  variety 
the  ordinary  symptoms  of  scarlet  fever  are  aggravated  by  the 
presence  of  faucial  ulceration,  which,  in  addition  to  being  a  serious 
lesion  in  itself,  provides  a  focus  from  which  septic  material  is 
absorbed  into  the  system.  The  temperature,  instead  of  declining 
during  the  latter  half  of  the  week,  remains  elevated  and  takes  on  an 
irregularly  remittent  character.  The  rash  may  be  intense,  and  is 
often  patchy,  and  delirium,  combined  with  restlessness,  is  usually 
present. 

The  most  characteristic  signs,  however,  are  swelling,  ulceration, 
or  even  necrosis  of  the  tonsils,  inflammatory  infiltration  of  the 
subjacent  glands  and  connective  tissue,  and  a  profuse  muco-purulent 
or  thin  straw-coloured  rhinorrhoea,  the  irritant  quality  of  which  often 
leads  to  excoriation  of  the  external  nares. 

The  tongue  peels  as  in  the  simple  form  of  attack,  but  a  few 
days  later  becomes  re-coated  with  a  dirty  white  fur,  which  assists  in 
imparting  an  offensive  odour  to  the  breath,  while  patches  of  super- 
ficial ulceration  may  develop  on  the  sides  of  the  tongue  or  at  the 
angles  of  the  mouth.  At  this  stage  there  is  often  albuminuria,  and 
diarrhoea  is  not  uncommon. 

Should  recovery  ensue,  a  gradual  improvement  in  all  respects 
sets  in  towards  the  end  of  the  second  week,  or  a  few  days  later, 
attended  with  subsidence  of  the  faucial  and  lymphatic  engorgement, 
delirium,  and  pyrexia.  The  ulceration  of  the  tonsils  heals,  and  the 
patient  is  again  able  to  swallow  without  distress  and  obtain  the 
benefit  of  sleep.  The  severity  of  the  tax  he  has  undergone  is  re- 
vealed by  the  degree  of  weakness,  loss  of  flesh,  and  aneemia  which 
is  present  at  the  commencement  of  convalescence.  This  in  some 
cases  may  not  take  place  until  the  expiration  of  more  than  three 
weeks  from  the  date  of  invasion. 

In  the  worst  cases  the  tonsillar  ulceration  takes  on  a  sloughing 
character,  attended  with  enormous  infiltration  of  the  tissues  of  the 
neck;  so  much,  indeed,  that  the  space  between  the  upper  border  of  the 
clavicle  and  the  lower  jaw  becomes  occupied  by  a  collar  of  brawny 
induration.  Or,  again,  the  ulceration  may  spread,  and  thus  involve 
the  pillars  of  fauces,  uvula,  and  soft  palate,  which,  in  some  cases, 
becomes  perforated,  or,  extending  downwards,  may  cause  extensive 
destruction  of  the  tissues  forming  the  upper  opening  of  the  larynx. 
The  mechanism  of  the  parts  becomes  interfered  with  in  consequence, 
and  any  attempt  at  swallowing  results  in  the  passage  of  food  into 
the  nares,  or  through  the  laryngeal  aperture.  Nor  is  the  patient 
able  to   sleep,  because   the  moment  he  drops  off  he  is  suddenly 


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284  MANUAL  OF  MEDICINE 

awakened,  half  choked,  by  the  passage  of  irritant  secretions  into  the 
larynx,  or  by  the  dropping  back  of  the  base  of  the  tongue  and 
epiglottis,  with  consequent  obstruction  to  the  breathing,  since  the 
nasal  passages  are  blocked  up  with  swelling  and  secretion.  For  its 
relief  tracheotomy  may  be  required.  The  exhaustion  entailed  by 
this  constant  distress,  coupled  with  the  severity  of  the  disease,  soon 
becomes  extreme,  and  the  patient  rapidly  sinks,  death  often  occurring 
between  the  tenth  and  fourteenth  days. 

In  cases  which  linger  on,  the  septicgemic  character  of  the  attack 
becomes  more  pronounced ;  profuse  sweats,  diarrhoea,  and  great 
emaciation,  albuminuria,  pulmonary  congestion,  or  septic  broncho- 
pneumonia commonly  arise  before  death,  which  may  not  take  place 
until  the  end  of  the  third  week.  Occasionally  a  pyjemic  condition 
supervenes,  characterised  by  the  appearance  of  secondary  abscesses 
in  the  glands,  connective  tissue,  joints,  or  pleurae.  Moreover,  a 
septic  rash  may  develop  during  the  latter  half  of  the  second  week. 
It  is  sometimes  erythematous,  and  more  often  morbilliform  in 
character,  and  limited  to  the  cheeks,  buttocks,  and  extensor  surface 
of  the  joints.  About  five  out  of  every  six  cases  attended  with  a 
septic  rash  are  fatal. 

III.  Toxic  form,  or  scarlatina  maligna. — In  this  variety 
the  gravity  of  the  condition  is  out  of  all  proportion  to  the  throat 
affection,  being  dependent  on  the  toxic  intensity  of  the  strictly 
scarlatinal  poison.  Cases  deserving  of  the  term  "malignant,"  in 
which  the  patient  is  struck  down  and  dies,  perhaps,  within  forty-eight 
hours,  before  the  typical  symptoms  of  the  disease  have  had  time  to 
develop,  are  extremely  rare  in  this  country  at  the  present  day ;  but 
we  occasionally  meet  with  attacks  to  which  the  term  "  semi-malig- 
nant "  may  be  fairly  applied.  They  are  characterised  by  great 
severity,  and  usually  prove  fatal  on  the  fourth,  fifth,  or  sixth  day  of 
the  disease. 

The  symptoms  of  invasion  are  unduly  severe,  especially  the 
vomiting,  which  may  be  incessant,  and  usually  persists  to  the  end. 
The  rash  is  very  intense,  with  a  tendency  to  become  petechial  as  the 
case  proceeds.  The  temperature  is  very  high,  and  shows  but  very 
slight  remission;  it  is  often  above  105°,  rarely  falling  below  104°, 
and  before  death  may  rise  to  over  106^.  The  pulse  is  extremely 
rapid,  in  children  often  registering  180  on  the  first  day  of  attack. 
The  fauces  are  red,  and  vividly  injected ;  but  there  may  be  very 
little  swelling  of  the  tonsils,  while  ulceration  or  marked  infiltration 
of  the  subjacent  lymphatic  glands  is  exceptional.  The  patient  is 
extremely  restless,     Delirium  or  stupor  are  always  present,  coupled 


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2  86  MANUAL   OF   MEDICINE 

with  pronounced  muscular  tremor.  In  adults  the  delirium  is  apt  to 
be  violent,  and  there  is  always  great  prostration.  In  most  cases 
coma  supervenes,  and  the  case  soon  proves  fatal.  Cadaveric  lividity 
sets  in  rapidly,  often  before  life  is  extinct ;  it  and  the  petechial 
character  of  the  eruption  are  expressive  of  the  intense  toxic  disinte- 
gration which  has  taken  place  in  the  blood. 

Of  the  complications  likely  to  arise  in  connection  with  scarlet 
fever,  the  following  list  enumerates  their  percentage  incidence, 
among  30,417  consecutive  attacks: — 


Otitis  media  . 
Simple  albuminuria 
Cervical  adenitis     . 
Arthritis 
Acute  nephritis 


14.74  I    Abscess          .          .  .  2.58 

8.26  '    Tonsillitis  (secondar}')  .  2.36 

5.66       Ulcerative  stomatitis  .  2.12 

3.75       Broncho-pneumonia  .  1.33 

3.12       Bronchitis      .          .  .  1.2 1 


With  the  exception  of  certain  other  infectious  diseases  to  which  the 
scarlatinal  convalescent  is  very  liable,  viz.  diphtheria,  chicken-pox, 
measles,  and  whooping-cough,  no  other  affection  showed  an  incidence 
as  high  as  i  per  cent. 

Otitis  ??iedia,  like  ulcerative  stomatitis  and  broncho-pneumonia, 
is  essentially  a  disease  of  young  children,  rarely  arising  after  ten 
years  of  age.  It  is  more  frequent  after  severe  attacks  than  mild 
ones,  and,  though  the  invasion  may  be  acute,  in  many  cases  otorrhcea 
is  the  first  and,  indeed,  the  only  symptom.  The  otorrhcea,  if 
continued,  may  lead  to  suppuration  of  the  mastoid  cells ;  and 
ultimately,  if  neglected,  be  followed  by  thrombosis  of  the  lateral 
sinus,  pyjemia,  abscess  of  the  brain,  or  meningitis 

Albuminuria,  like  acute  nephritis,  which  is  the  expression  of  the 
same,  though  more  severe,  lesion  of  the  kidney,  is  as  common  after 
a  mild  attack  of  undoubted  scarlet  fever  as  after  a  severe  one.  They 
most  often  arise  during  the  latter  half  of  the  second  and  the  third 
week,  but  occasionally  somewhat  later.  Cold,  in  itself,  seems  to 
have  but  little  influence ;  but  in  raw,  damp,  or  even  "  muggy " 
weather  the  Hability  is  greater.  Acute  nephritis  associated  with 
scarlet  fever  is  noteworthy,  in  that  h^ematuria  is  constant,  and  a 
relatively  prominent  symptom,  whereas  dropsy  of  any  degree  is 
rare,  and  complete  recovery  the  rule  under  early  and  appropriate 
treatment. 

The  cei^ical  adenitis  referred  to  arises  during  convalescence, 
usually  during  the  third  and  fourth  weeks  of  illness,  and  is  attended 
with  a  fresh  rise  of  temperature.  It  is  often  associated  with  nephritis, 
and  suppuration  is  not  uncommon. 


SCARLET  FEVER  .287 

■  Arthritis^  like  secondary  tonsillitis,  usually  affects  adults  and 
older  children,  especially  females.  Its  time  of  onset  is  remarkably 
constant,  viz.  the  fifth,  sixth,  or  seventh  day  of  attack,  just  when  the 
temperature  is  falling  to  normal.  The  arm  is  more  often  affected 
than  the  leg,  the  smaller  joints  than  the  large,  and  the  wrists  and 
metacarpal  joints  most  of  all ;  the  heart  and  pericardium  are  very 
rarely  affected,  and  recovery  is  usually  rapid. 

An  abscess  may  occur  in  any  situation,  especially  after  a  septic 
attack.  Its  most  frequent  seat  is  in  the  glands  of  the  neck  and 
over  the  mastoid  bone,  in  the  latter  case  usually  preceded  by  otor- 
rhoea.     Suppurative  arthritis  and  empyema  occur  sometimes. 

Ulcerative  stomatitis  is  usually  a  mild  affection ;  but  in  delicate 
children,  though  fortunately  rarely,  it  may  assume  a  sloughing 
character,  and  lead  to  alveolar  necrosis  or  perforation  of  the  cheek. 
Noma  vulvae  is  occasionally  seen. 

Broncho-pneumonia  is  prone  to  arise  in  the  course  of  a  septic 
attack  in  a  young  child,  and  is  frequently  fatal. 

Chorea  has  been  sometimes  observed  to  follow  scarlet  fever.  It 
is,  however,  an  extremely  rare  sequela,  and  it  is  very  doubtful 
whether  the  association  can  be  regarded  as  more  than  accidental. 

Bacteriology. — Scarlet  fever  is,  no  doubt,  due  to  the  specific 
activity  of  some  micro-organism  which  multiplies  within  the  system. 
So  far,  however,  its  identity  has  not  been  conclusively  established, 
though  Klein  has  demonstrated  the  presence  in  the  blood  and  fauces, 
in  certain  cases  of  scarlet  fever,  of  a  streptococcus  which  he  regards 
as  distinctive.  Its  presence  has  been  confirmed  by  other  observers, 
but  it  is  usually  regarded  as  dependent  upon  the  septic  element 
which  is  present  in  most  severe  attacks. 

There  is  reason  to  beheve  that  the  scarlatinal  virus  undergoes 
multiplication  in  the  blood  rather  than  in  the  throat  or  skin,  though 
infection  is  doubtless  transmissible  through  these  channels. 

The  post-mortem  appearances  observed  in  the  organs  are 
not  very  distinctive  of  scarlatina,  but  are  for  the  most  part  common 
to  the  febrile  state.  In  the  intestines,  however,  a  distinct  enlarge- 
ment of  the  lymphatic  foUicles  is  noticeable, — perhaps  more  often 
than  not, — and  in  rare  instances  ulceration.  The  kidneys  present 
no  constant  appearance  in  scarlatina;  but  should  any  evidence  of 
renal  involvement  have  been  apparent  during  life,  signs  of  glomerular 
nephritis,  with  or  without  marked  interstitial  change,  will  be  present, 
according  as  the  case  was  fatal  at  an  early  or  late  stage  of  the 
disease. 

The  general  mortality  of  an  outbreak  of  scarlet  fever,  like 


288  MANUAL  OF  MEDICINE 

that  of  diphtheria,  is  mainly  regulated  by  the  comparative  number 
of  young  children  amongst  those  attacked,  and  the  degree  of 
poverty  in  which  they  exist.  The  fatality  of  scarlet  fever  at  the 
present  time  in  London  at  large  is  about  4  per  cent.  The  case 
mortality  of  81,605  cases  treated  in  the  hospitals  of  the  Metro- 
politan Asylums  Board  during  the  years  1892-97  was  5.3  per  cent 
(see  table  on  p.  275). 

The  prognosis  in  an  individual  attack  is  influenced  by  certain 
personal  factors,  viz.  age,  sex,  and  state  of  health,  apart  from  any 
inference  to  be  drawn  from  the  type  of  attack. 

The  case  mortality  progressively  falls  with  each  year  of  life  until 
the  time  of  puberty,  from  whence  until  about  the  thirtieth  year  it  is  at 
its  lowest.  Afterwards  a  slight  rise  occurs.  In  the  series  referred 
to  above,  the  mortality  for  the  first  three  quinquennia  was  12.4,  3, 
and  1.2  per  cent  respectively. 

The  influence  of  sex  is  not  very  great,  but  the  fatality  amongst 
males  is  the  higher. 

Scarlet  fever  is  very  prone  to  take  a  bad  form  in  ill-fed, 
strumous,  and  tuberculous  subjects.  Pulmonary  tuberculosis,  pre- 
viously latent,  is  apt  to  be  lighted  up,  and  hurried  to  a  fatal  issue. 
During  the  puerperium  there  is  a  great  tendency  for  scarlet  fever 
to  develop  into  fatal  septicaemia.  In  persons  suffering  from  chronic 
renal  disease  an  attack  of  scarlet  fever  usually  sets  up  fresh 
nephritis,  which  is  very  likely  to  prove  fatal. 

Severity  of  faucial  swelling  and  ulceration,  especially  if  attended 
with  much  adeno-cellular  infiltration  and  a  high  temperature,  is  a 
bad  sign,  as  indicating  a  septic  attack ;  while  extreme  restlessness 
and  persistent  vomiting,  with  a  petechial  rash,  high  temperature, 
early  mental  impairment,  and  muscular  tremor,  point  towards  toxic 
intensity,  and  consequently  danger  to  life.  DeUrium  in  an  adult 
implies  a  severe  attack,  while  convulsions  in  a  young  child,  arising 
subsequent  to  the  stage  of  invasion,  are  practically  always  fatal. 

The  differential  diagnosis  of  scarlet  fever  from  measles  and 
rotheln  is  discussed  in  the  articles  relating  to  those  diseases. 
Simple  tonsillitis  rarely  affects  young  children,  but  in  an  adult  may 
lead  to  confusion,  especially  if  attended  with  a  rash.  The  absence, 
however,  of  distinct  punctation,  vomiting,  peeling  of  the  tongue, 
and  desquamation  will  usually  decide  its  nature,  while  the  appear- 
ance of  arthritis  towards  the  end  of  the  week,  or  of  albuminuria  or 
nephritis  during  convalescence,  point  strongly  to  scarlet  fever. 

In  the  treatment  of  scarlet  fever  a  specific  virtue  has  been 
claimed  for  many  drugs.     None  of  them,  however,  have  yet  been 


SCARLET  FEVER  289 

shown  capable  of  exerting  the  least  influence  over  the  course  of 
the  disease.  Happily,  the  large  proportion  of  attacks  are  mild, 
and  no  active  treatment  is  called  for.  It  is  usually  sufficient  to 
isolate  the  patient  in  a  well-ventilated  room,  maintained  at  a 
temperature  of  from  56'  to  60'  F.,  to  sponge  the  surface  of  the  body 
over  at  least  once  a  day  with  tepid  water,  and  see  that  he  is  suit- 
ably fed  and  warmly,  though  not  too  heavily,  covered. 

Should  the  throat  feel  sore  and  the  fauces  be  red  and  tumid,  a 
mild  astringent  gargle  or  spray  of  boric,  tannic,  or  weak  sulphurous 
acid  may  be  used  every  few  hours.  The  constant  sucking  of  pieces 
of  ice,  or  the  frequent  sipping  of  an  iced  lemonade,  containing  a 
drachm  of  bitartarate  and  chlorate  of  potash  to  the  pint,  will  prove 
distinctly  comforting.  A  linseed-meal  poultice  or  hot  fomentation, 
renewed  frequently,  may  be  applied  to  the  neck  should  tenderness 
of  the  glands  be  complained  of,  and  the  bowels  should  be 
regulated  by  means  of  a  gentle  aperient.  The  diet  during  the 
febrile  stage  should  mainly  consist  of  milk  and  beef-tea  or  broth,  • 
with  the  addition  of  jelly  and  grapes  or  oranges  if  desired ;  and  a 
light  solid  diet  containing  fish,  milk-pudding,  bread  and  butter,  and 
eggs  may  be  allowed  as  soon  as  the  temperature  is  normal  and  the 
patient  is  inchned  to  swallow  it.  From  this  time  onwards  a  warm 
bath  may  be  given  every  night  with  advantage.  If  the  attack 
has  been  mild  the  patient  may  be  allowed  to  get  up  at  the  end  of 
ten  days  or  a  fortnight,  and  go  out  of  doors  a  day  or  two  later  in 
fine  weather.  Care  should  be  taken  that  he  is  warmly  clad  and 
does  not  get  wet  or  sit  about  on  a  damp  day. 

In  cases,  however,  in  which  the  fauces  are  much  inflamed,  and 
especially  if  the  tonsils  are  at  all  ulcerated,  or  even  if  they  threaten 
to  become  so,  energetic  local  treatment  should  be  at  once  adopted 
with  the  object  of  preventing  the  development  of  a  septic  focus 
from  which  absorption  would  necessarily  follow.  To  this  end, 
nothing  is  better,  or  indeed  so  good,  as  the  irrigation  of  the  fauces 
and,  if  necessary,  the  nasal  passages  every  two,  three,  or  four  hours 
with  the  acid  solution  of  chlorate  of  potash,  containing  free  chlorine, 
which  is  so  useful  in  faucial  diphtheria.  It  is  made  in  the  follow- 
ing proportions  : — -5  minims  of  strong  hydrochloric  acid  poured  on 
to  9  grains  of  powdered  chlorate  of  potash,  to  which  is  gradually 
added,  with  frequent  shaking,  i  ounce  of  water.  Mixed  with  an 
equal  volume  of  hot  water,  about  half  a  pint  of  the  solution  is  used 
on  each  occasion  in  the  following  manner : — 

The  patient  sits  up  in  bed  with  his  head  inclined  forwards  over 
a  basin  which  he  supports  on  his  knees.     Into  his  open  mouth  the 
VOL.  I  U 


290  MANUAL  OF  MEDICINE 

nurse,  standing  on  the  right  side  of  the  bed,  with  her  left  hand 
supporting  his  head,  passes  in  a  backward  direction  the  nozzle  of  a 
four-ounce  rubber  enema  bottle  charged  with  the  solution,  which 
she  then  injects  with  moderate  force  so  as  to  thoroughly  wash  out 
the  faucial  passage.  The  liquid  runs  out  of  the  mouth  and  is 
caught  in  the  basin  underneath.  Care  should  be  taken  to  pause 
between  each  squeeze  of  the  syringe,  in  order  to  allow  the  patient 
an  opportunity  of  taking  a  breath.  The  irrigation  is  to  be  con- 
tinued until  the  solution  is  used  up ;  and,  should  there  be  any 
rhinorrhoea,  the  nasal  passages  must  be  treated  in  the  same  way, 
though  more  gently,  and  the  patient  directed  to  keep  his  mouth 
open  in  order  to  facilitate  the  return  of  the  solution  through  the 
other  nostril,  rather  than  allow  it  to  run  down  the  throat  and  set 
up  coughing  through  entering  the  larynx.  By  thus  thoroughly 
flushing  out  the  fauces,  pharynx,  and  nasal  fossae  at  frequent 
intervals  with  an  astringent  antiseptic  solution,  all  offensive  secre- 
tions are  cleared  away,  and  the  parts  kept  in  a  clean  and  whole- 
some condition ;  a  result  which  cannot  be  attained  by  means  of 
any  gargle,  spray,  or  swab.  Should  the  chlorine  cause  vomiting,  a 
half  per  cent  solution  of  formalin  with  equal  parts  of  water,  or  one 
of  boric  acid,  may  be  employed ;  but  neither  are  so  efficacious. 

The  inflammatory  infiltration  of  the  glands  and  cellular  tissue 
in  the  neck,  which  is  frequently  present  in  a  septic  attack,  may 
necessitate  incision.  In  such  cases  it  is  better  not  to  wait  for 
definite  evidence  of  suppuration,  but  the  brawny  swelling  should 
be  incised  in  several  places  and  tension  thus  relieved.  Afterwards 
hot  boric  acid  fomentations  should  be  applied. 

In  young  children  it  is  sometimes  necessary  to  feed  by  nasal 
tube  or  enema,  in  consequence  of  the  difficulty  in  getting  them  to 
swallow,  and  in  all  septic  attacks  a  little  brandy  should  be  given  at 
frequent  intervals. 

In  toxic  attacks  but  little  can  be  done  beyond  supporting  the 
strength  as  far  as  possible  by  means  of  stimulants  and  concen- 
trated nourishment.  Unfortunately,  the  persistent  vomiting  so 
often  precludes  satisfactory  oral  feeding.  The  high  temperature 
usually  proves  refractory  alike  to  the  influence  of  cold  applications 
and  of  antipyretic  drugs,  but  the  cold  pack  is  not  without  value  as 
a  sedative.  The  complications  which  are  liable  to  super^^ene 
during  convalescence  from  scarlet  fever  demand  the  same  treat- 
ment as  when  arising  independently. 

F.  FooRD  Caiger 


ACUTE  AND  SUBACUTE   RHEUMATISM  291 


ACUTE  AND   SUBACUTE  RHEUMATISM 
Syn.  Rheumatic  Fever 

To  understand  the  disease  known  as  "acute  rheumatism"  it 
must  be  studied,  first  and  chiefly,  in  the  child.  For  in  childhood 
it  is  more  frequent,  more  varied,  and  more  virulent  than  in  the 
adult.  The  earliest  period  of  life  is,  indeed,  almost  exempt,  for 
rheumatic  symptoms  are  hardly  ever  seen  before  two  years  of  age. 
But  if  the  frequency  of  rheumatism  were  represented  by  a  curve,  the 
vertical  height  of  which  indicated  the  number  of  cases  at  each 
successive  year  of  Ufe,  it  would  be  found  that  the  maximum  height 
of  the  curve  would  be  at  or  about  ten  years.  The  rise  to  this  height 
would  be  rather  rapid,  the  fall  much  more  gradual.  At  the  age  of 
forty  the  curve  would  nearly  have  reached  the  base-line.  The 
manifestations  of  the  disease  are  more  varied  in  the  child  than  in 
the  adult ;  some  of  the  phenomena  fairly  common  in  the  former 
are  rarely  seen  in  the  latter.  It  is  also  more  virulent ;  an  acute 
attack  rarely  proves  fatal  in  an  adult,  but  this  is  much  less  un- 
common in  children. 

Clinical  characters. — The  invasion  is  moderately  abrupt, 
sometimes  preceded  or  accompanied  by  slight  sore-throat.  In  a 
day  or  two  the  temperature  rises  to  about  102°,  vague  pains  are 
complained  of,  and  the  child  loses  appetite.  There  may  be  slight 
effusion,  with  pain  and  tenderness,  in  one  joint,  perhaps  even  in 
two  or  three,  but  the  arthritic  phenomena  are  often  very  sHght,  and 
may  easily  be  overlooked  altogether. 

Yet  even  in  the  slightest  cases  the  heart  may  be  affected.  An 
acute  dilatation  seems  to  be  almost  invariable.  If  the  "  deep " 
cardiac  dulness  be  carefully  delimited  by  fight  percussion,  it  will 
almost  always  be  found  to  be  larger  than  normal.  In  the  healthy 
child  this  dufi  area  extends  from  one  finger-breadth  (or  rather  less) 
to  the  right  of  the  right  border  of  the  sternum  in  the  fourth  inter- 
costal space  to  just  within,  or  in  children  under  seven  quite  up  to, 
the  left  nipple -line.  In  the  child  suffering  from  rheumatism  the 
heart  will  be  found,  on  careful  examination,  to  extend  to  the  left  of 
the  nipple-line  from  a  half  to  one  finger-breadth,  but  the  right  fimit 
is  usually,  in  a  first  attack,  imaltered.  This  indicates  a  definite 
dilatation  of  the  left  ventricle.      The   first  sound  at  the  apex  is 


292  MANUAL  OF  MEDICINE 

altered  in  quality ;  it  is  less  loud  and  clear  than  normal  and  usually 
shorter,  though  it  may  be  prolonged  into  a  systolic  murmur.  At 
the  base  the  pulmonary  second  sound  is  too  loud.  The  cardiac 
impulse  is  diminished  in  strength,  and  felt  over  too  large  an  area ; 
the  maximum  is  in  the  nipple-line,  or  even  slightly  to  the  left  of  it. 
These  phenomena  may  easily  escape  notice,  but  they  are  of  great 
importance.  They  show  that  the  affection  of  the  heart  in  rheumatism 
is  in  no  sense  a  "  complication  " ;  it  is  a  characteristic,  and  the  most 
important,  part  of  the  disease. 

Greater  severity  of  rheumatic  attack  in  a  child  manifests  itself 
less  by  increase  of  arthritis  than  by  a  fiercer  assault  upon  the  heart. 
Several  (or  even  many)  joints  may  be  affected,  but  in  children  the 
arthritis  is  usually  less  severe  and  more  transient  than  in  the  adult. 
The  heart  often  sustains  grievous  damage,  the  effects  of  which  are 
permanent.  The  acute  dilatation  is  more  marked  than  in  the 
slighter  cases,  and  is  probably  due  to  definite  myocarditis,  in 
addition  to  the  toxic  action  on  the  cardiac  muscle  which  seems  to 
be  the  cause  of  the  minor  degrees  of  acute  dilatation.  Endocarditis 
is  common,  the  mitral  being  almost  invariably  the  valve  first 
affected,  causing  a  systolic  apex  murmur  which  tends  to  be  con- 
ducted towards  the  axilla.  This  must  not  be  confounded  with  the 
systolic  murmur  over  the  right  ventricle,  which  is  not  uncommon  in 
healthy  children.  A  systolic  murmur  at  the  apex  in  a  rheumatic 
attack  may  perhaps  sometimes  be  due  to  ansemia,  but  endocarditis 
should  always  be  suspected.  After  a  time  it  may  be  observed  in  many 
cases  that  the  systolic  murmur  is  followed  by  a  double  second  sound 
heard  only  at  the  apex.  The  first  element  of  this  double  second  sound 
is  probably  the  normal  second  sound  of  the  heart ;  the  second  element 
is  probably  produced  by  tension  of  a  slightly  thickened  and  stiffened 
mitral  flap,  resulting  from  the  active  ventricular  dilatation  which 
normally  occurs  at  the  commencement  of  diastole.  The  first 
element  of  this  double  second  sound  never  changes  its  character  as 
long  as  it  is  audible  at  all.  But  in  many  cases  the  second  element 
becomes  altered  from  the  sharp  sound  of  tension  into  a  short  blow- 
ing murmur,  the  effect  of  vibration  of  the  stiffened  mitral  caused  by 
the  commencing  inrush  of  blood  from  the  auricle  into  the  ventricle. 
Sometimes,  and  especially  on  auscultation  a  little  more  internally, 
this  murmur  in  the  early  part  of  the  diastolic  period  is  found  to  be 
replaced  by  a  similar  short  blowing  murmur  of  presystolic  time. 
This  is  no  doubt  produced  by  vibration  of  the  stiffened  mitral 
caused  by  the  greater  force  of  the  blood  current  during  the  auricular 
systole,  but  it  must  not  be  taken  to  mean  any  definite  narrowing  of 


ACUTE  AND   SUBACUTE  RHEUMATISM  293 

the  mitral  orifice.  After  a  while  the  doubling  of  the  second  sound 
at  the  apex  disappears.  This  perhaps  means  that  slight  shortening 
has  occurred  in  the  valve  or  its  chordae,  the  result  of  contraction  of 
the  new  fibrous  tissue,  so  that  its  tension  occurs  earlier  and  again 
coincides  with  the  normal  second  sound,  or  that  the  early  diastolic 
murmur,  growing  more  definite,  commences  at  the  earliest  instant  of 
the  diastolic  expansion  and  obliterates  the  second  sound. 

Pericarditis  may  occur  even  in  a  first  attack.  It  is  a  symptom 
of  danger,  for  it  is  usually  associated  with  great  increase  of  the 
cardiac  dilatation,  indicating  probably  a  profound  affection  of  the 
heart-muscle.  The  first  evidence  of  pericarditis  may  be  vomiting, 
or  subjective  distress,  or  a  disturbance  of  the  cardiac  rhythm  (so 
that  it  becomes  triple  or  confused) ;  or  else  an  audible  rub,  heard 
over  some  part  of  the  cardiac  area,  usually  first  at  the  base  and 
later  over  the  right  ventricle,  sometimes  even  at  the  apex  and  to 
the  right  of  the  sternum.  The  quality  of  the  friction-sound  is' 
usually  rough,  often  so  rough  as  to  resemble  scratching  or  tearing, 
but  at  the  base  it  may  at  first  be  so  soft  as  to  simulate  a  double 
aortic  murmur.  The  cardiac  dulness  is  almost  always  enlarged 
before  the  rub  is  heard,  and  it  soon  becomes  further  increased. 
It  is  possible  that  this  increase  may  to  some  extent  be  caused  by 
effusion  of  fluid  into  the  pericardial  sac,  but  post-mortem  evidence 
shows  that,  though  the  whole  heart  may  be  covered  with  plastic 
lymph,  there  is  rarely  any  great  increase  in  the  pericardial  fluid, 
and  that  sometimes  none  at  all  is  found  even  where  the  increase  in 
the  dulness  is  most  extensive.  On  the  other  hand,  marked  dilata- 
tion is  found  to  be  very  common,  and  extreme  dilatation  is  not  rare.^ 
The  outline  of  the  precordial  dulness  affords  very  little  assistance 
in  determining  whether  fluid  pericardial  effusion  is  present  in 
addition  to  the  cardiac  dilatation,  but  decided  extension  of  dul- 
ness to  the  left  of  the  sternum  in  the  second  and  third  inter- 
costal spaces  is  in  favour  of  some  effusion,  for  this  usually  is  most 
abundant  at  first  about  the  great  vessels. 

Cases  of  rheumatism  in  which  pericarditis  and  great  dilatation 
of  the  heart  are  present  often  exhibit  symptoms  of  grave  cardiac 
failure^  due  no  doubt  to  the  damaged  state  of  the  cardiac  muscle. 
Dyspncea  is  marked,  and  may  be  extreme,  even  in  the  absence  of 
any  lung  complication.  It  is  probably  the  exaggeration  of  a  normal 
reflex  from  the  right  ventricle  to  the  respiratory  centre,  by  which  an 
overstrained  right  ventricle  is  automatically  relieved.^  The  failure  of 
the  left  ventricle  is  shown  by  the  feebleness  and  frequency  of  the 

^  Vide  Med. -Chi.  Trans.   1898,  p.  447.     ^  Lancet,   1893,  vol.  ii.  p.  1050, 


294  MANUAL  OF   MEDICINE 

pulse.  Vomiting  and  delirium  may  also  occur,  the  former  probably 
of  reflex  origin,  the  latter  analogous  to  the  delirium  sometimes  seen 
at  the  end  of  a  case  of  chronic  heart  disease.  Fortunately,  peri- 
carditis does  not  often  produce  much  pain,  though  it  causes  local 
tenderness.  Coexisting  pleurisy  may  cause  pain.  It  is  revealed  by 
a  pleural  rub  in  one  or  both  axillae,  or  along  the  left  border  of  the 
heart ;  in  the  latter  position  the  rub,  though  of  pleural  origin,  may 
be  of  cardiac  rhythm.  Rheumatic  pleurisy  rarely  leads  to  much 
effusion  of  fluid,  being  in  this  respect  similar  to  rheumatic  pericar- 
ditis. Pneumonia  is  a  somewhat  rare  complication  ;  it  adds  greatly 
to  the  danger.  Both  the  pleurisy  and  the  pneumonia  of  rheuma- 
tism prefer  the  left  side. 

These  affections  of  the  thoracic  organs  are  the  points  on  which 
the  attention  of  the  physician  ought  to  be  primarily  fixed  when 
called  to  see  a  child  suffering  from  even  the  mildest  attack  of 
rheumatism.  The  more  external  manifestations  of  the  disease  in 
skin,  joints,  and  fibrous  tissues,  are  not  of  vital  importance.  But 
they  are  often  of  much  use  in  diagnosis,  and  some  description  of 
them  is  necessary  to  complete  the  clinical  picture. 

The  affected  joints  are  usually  only  slightly  swollen.  They  are 
distinctly  tender  and  painful,  but  neither  swelling,  tenderness,  nor 
pain  is  equal  to  what  is  often  observed  in  the  same  disease  at  a 
later  period  of  life.  There  may  be  hyperaemic  patches  of  skin  over 
these  joints,  but  they  usually  soon  disappear.  There  may  also  be 
some  pain  and  tenderness  in  the  adjacent  tendons,  especially  behind 
the  knees.  Pain  and  tenderness  in  the  cervical  spinal  articulations 
or  in  the  tendinous  insertions  of  the  cervical  muscles  may  cause 
stiffness  and  immobility  of  the  neck,  simulating  caries  of  the 
cervical  spine. 

In  the  neighbourhood  of  the  joints,  and  in  fibrous  tissues 
elsewhere,  children  often  manifest  a  form  of  rheumatic  affection 
which  is  rarely  seen  in  adults.  Small,  firm,  sUghtly  movable  sub- 
cutaneous nodules^  not  painful,  but  sometimes  slightly  tender,  are 
found  over  prominent  bony  points,  especially  over  the  ends  of  the 
long  bones,  the  vertebral  spinous  processes,  and  the  iliac  crests  ;  also 
in  tendinous  structures,  such  as  the  pericranium,  the  sternal  apo- 
neuroses, and  the  flexor  and  extensor  tendons  of  the  fingers  and 
toes.  They  exist  in  about  one-fourth  of  the  cases  of  rheumatism  in 
children.  Sometimes  only  a  single  nodule  may  be  discoverable,  in 
other  instances  only  two  or  three,  but  there  are  often  many,  and 
more  than  fifty  may  be  present  at  the  same  time.  The  smaller 
nodules  are  of  the  size  of  a  pin's  head ;  the  largest  commonly  met 


ACUTE  AND  SUBACUTE  RHEUMATISM  295 

with  are  about  equal  to  a  pea,  though  still  larger  ones  are  occasionally 
seen.  There  may  be  a  simultaneous  outburst  of  many  nodules, 
followed  by  their  gradual  disappearance,  and  a  subsequent  appear- 
ance of  a  fresh  crop.  Some  may  vanish  in  a  few  days,  others 
remain  for  many  months  or  even  for  more  than  a  year.  The 
existence  of  many  or  of  large  nodules  is  certainly  one  of  the 
indications  of  an  intense  rheumatic  process,  and  makes  it  prob- 
able that  serious  progressive  morbid  change  is  occurring  in  the 
heart. 

These  nodules  were  carefully  described,  and  their  histological 
structure  investigated,  by  Prof.  Hirschsprung  of  Copenhagen  in 
1879,  also  by  Dr.  Barlow  and  Dr.  Warner  in  1881.  They  were 
found  to  consist  mainly  of  fibrous  tissue  with  some  cells  (round  or 
spindle-shaped),  dilated  vessels,  and  a  certain  amount  of  nearly 
homogeneous,  more  or  less  fibrillated  "ground-substance."  Recently 
Dr.  Poynton  and  Dr.  Still  have  brought  forward  evidence  to  show 
that  this  homogeneous  substance  is  in  reality  a  fibrinous  exudation, 
and  therefore  probably  the  manifestation  of  a  local  rheumatic  in- 
flammation. They  thus  confirm  the  suggestion  of  Drs.  Barlow  and 
Warner  that  these  nodules  are  homologous  with  the  inflammatory 
exudation  which  forms  the  base  of  a  "  vegetation "  on  a  cardiac 
valve,  and  also  with  that  found  on  the  pericardium  in  rheumatic 
pericarditis.  Occasionally  quite  unmistakable  nodules  have  been 
seen  both  on  the  pericardium  and  on  the  mitral  valve. 

Rheufnatic  manifestations  in  the  skin  are  not  uncommon.  Excess 
of  sweating  is  sometimes  observed,  but  is  seldom  profuse  in  children. 
A  definite  rheumatic  eruption  shows  itself  in  not  a  few  cases.  It 
is  usually  an  erythema ; — papular  spots,  or  small  circular  areas  with 
slightly  raised  hypersemic  margins  and  paler  centres,  or  larger  areas 
with  irregular  outline  formed  by  coalescence  \  it  is  perhaps  most 
frequent  about  the  joints,  though  it  may  occur  on  the  trunk.  In 
rare  cases  the  erythema  becomes  vesicular  or  purpuric,  or  there 
may  be  numerous  petechiee,  especially  on  the  legs  and  feet.  But 
erythema  nodosum  is  probably  not  a  manifestation  of  rheumatism, 
though  it  may  occasionally  be  found  in  a  rheumatic  subject ;  it 
appears  to  be  an  independent  exanthem,  with  a  pyrexial  course 
of  definite  length  and  a  characteristic  eruption. 

In  the  micscles  vague  pains  may  be  felt,  and  some  distinct  atrophy 
is  occasionally  observed  after  a  rheumatic  attack.  When  there 
is  also  slight  numbness  and  some  defect  of  cutaneous  sensibility, 
there  is  reason  to  suspect  a  local  neuritis. 

Tonsillitis,  sometimes  of  the  "follicular"  variety,  may  precede  or 


296  MANUAL  OF  MEDICINE 

accompany  rheumatic  symptoms,  or  there  may  be  a  generalised 
pharyngitis. 

Anmnia  is  often  a  prominent  feature  of  a  rheumatic  attack ;  it 
may  be  rapidly  produced  or  intensified. 

Chorea  is  frequently  associated  with  rheumatism  in  childhood. 
The  relationship  between  the  two  affections  needs  further  elucidation, 
but  the  more  carefully  they  are  studied,  the  more  intimate  it  is  found 
to  be.  Choreic  symptoms  of  slight  intensity  are  common  in  children 
suffering  from  acute  or  subacute  rheumatism,  and  when  there  is  no 
definite  chorea  there  may  sometimes  be  seen  the  tendency  to 
emotional  disturbance,  the  causeless  and  transient  fits  of  crying, 
which  are  so  often  observed  in  chorea.  The  onset  of  a  severe 
chorea  frequently  follows  two  or  three  weeks  after  the  occurrence  of 
symptoms  which,  though  slight,  were  definitely  rheumatic.  During 
an  attack  of  chorea  undoubted  symptoms  of  rheumatism  may 
manifest  themselves.  Many  cases  of  chorea  which  have  apparently, 
at  the  time,  no  connection  with  rheumatism,  suffer  from  an  attack 
of  that  disease  a  year  or  two  later.  After  making  allowance  for 
possible  coincidences,  the  conclusion  is  irresistible  that  there  is 
some  very  close  connection  between  the  two  diseases,  and  that  in 
many  cases  chorea  must  be  looked  upon  as  a  definitely  rheumatic 
symptom. 

A  rheumatic  attack  which  has  been  inadequately  treated,  or  in 
which  the  treatment  has  been  suspended  too  soon,  is  very  apt  to 
relapse.  Symptoms  which  had  almost  or  altogether  subsided  may 
return,  or  fresh  rheumatic  symptoms  may  show  themselves.  This 
is  a  fact  of  the  greatest  importance  and  one  to  be  constantly 
remembered  in  the  treatment  of  even  the  mildest  cases.  In  some 
patients  this  tendency  to  relapse  is  specially  strong,  and  can  be 
overcome  only  by  regular  and  persistent  treatment  carried  on  for  a 
long  time.  Even  after  health  has  apparently  been  restored  and  all 
rheumatic  symptoms  have  entirely  subsided,  there  is  in  children  a 
very  strong  tendency  to  recurrence  of  the  disease  a  few  months 
later,  or  after  a  year  or  two.  Many  have  three,  four,  or  more 
attacks.  If  rheumatism  were  simply  an  arthritis,  this  would  perhaps 
be  of  little  consequence.  But  the  fact  that  in  almost  every  attack 
the  heart  is  more  or  less  affected  makes  such  recurrences  a  serious 
calamity.  Too  often  the  dilatation  of  the  heart  produced  by  the 
first  attack  has  not  subsided  when  a  second  attack  dilates  it  further, 
even  if  no  definite  endocarditis  or  pericarditis  is  produced. 
Enormous  dilatation  may  thus  be  brought  about ;  the  heart  may 
extend  nearly  to  the  right  nipple  fine  and  beyond  the  left  anterior 


ACUTE  AND   SUBACUTE   RHEUMATISM  297 

axillary  line,  the  left  border  rising  two  or  even  three  finger-breadths 
above  the  left  nipple.  These  dimensions  can  easily  be  demonstrated 
by  careful  percussion,  and  they  are  confirmed  by  autopsy. 

In  a  secojzd  or  siibseqimit  attack  of  rheumatism,  in  addition  to 
increased  cardiac  dilatation,  there  is  often  distinct  evidence  of 
permanent  damage  to  the  mitral  valve,  and  reason  to  suspect  fresh 
endocarditis.  The  systolic  murmur  is  louder  and  conducted  to  the 
angle  of  the  scapula ;  it  is  often  accompanied  by  a  much  shorter 
blowing  murmur  of  early-diastolic  or  of  presystolic  time.  In  some 
cases  an  aortic  regurgitant  murmur  becomes  audible,  but  this  is 
much  less  common.  At  a  later  period  the  early-diastolic  apex 
murmur  tends  to  disappear,  and  the  presystolic  murmur  becomes 
slightly  vibratile,  the  vibrations  becoming  coarser  as  the  years  go  by. 
But  it  is  very  rare  to  find  in  children  under  ten  a  churning  murmur 
at  all  Hke  that  which  is  characteristic  of  the  mitral  stenosis  of 
young  adults.  The  narrowing  of  the  orifice  is  a  slow  process  and 
requires  several  years  for  its  development. 

Pericarditis  is  less  frequent  than  dilatation  and  endocarditis,  but 
it  is  the  mark  of  a  specially  acute  rheuniatic  attack,  and  it  greatly 
increases  the  danger.  It  is  usually  accompanied  by  marked  increase 
of  the  dilatation,  and  symptoms  of  cardiac  failure  are  not  far  off.  It 
rarely  leads  to  any  great  amount  of  fluid  effusion  into  the  peri- 
cardium, in  spite  of  the  current  teaching  on  this  subject,  which  is 
founded  on  the  erroneous  assumption  that  the  increase  of  the  pre- 
cordial dulness  is  entirely  caused  by  effusion  of  fluid  into  the  peri- 
cardial sac,  and  that  it  is  an  accurate  indication  of  the  amount  of 
such  effusion.  Plastic  lymph,  more  or  less  organised,  is  found  in 
a  fatal  case,  and  often  much  thickening  of  the  pericardium,  but 
seldom  much  fluid,  and  sometimes  hardly  any  at  all.  More  or  less 
pericarditis,  old  or  recent,  is  found  in  about  three-fourths  of  the 
fatal  cases ;  in  about  one-half  the  pericardial  surfaces  are  found  to 
be  entirely  adherent. 

Extensive  venous  thrombosis  has  been  met  with  shortly  before 
death  in  a  few  cases ;  Dr.  Poynton  has  recently  drawn  attention  to 
this. 

Below  the  age  of  ten  years,  girls  and  boys  are  equally  liable  to 
suffer  from  rheumatism.  But  from  ten  to  fifteen  years  of  age,  girls 
are  twice  as  liable  as  boys  to  rheumatism,  and  three  times  as  liable 
to  chorea.  This  may  possibly  be  in  some  way  connected  with  the 
more  rapid  development  of  girls  than  of  boys  during  these  years, 
the  girls  gaining  both  in  height  and  weight  more  rapidly  than  the^ 
boys.      The  greater  liability  of  girls  between   ten   and  fifteen  to 


298  MANUAL   OF   MEDICINE 

rheumatism  and  to  chorea  goes  a  long  way  to  explain  why  mitral 
stenosis  is  so  much  more  frequent  in  women  than  in  men. 

In  adolescents,  from  fifteen  to  eighteen  years  of  age,  rheuma- 
tism is  less  common,  for  many  of  the  most  susceptible  subjects 
have  been  already  eliminated.  It  is  also  on  the  whole  less  virulent. 
Pericarditis  is  now  less  commonly  fatal,  but  it  often  produces 
permanent  crippling  of  the  heart.  Dilatation  is  almost  invariable. 
Endocarditis  is  common.  The  evidence  of  former  heart  disease  is 
often  marked ;  it  takes  two  forms.  One  is  that  of  a  dilated  heart, 
wdth  or  without  evidence  of  pericardial  adhesions,  with  a  loud, 
long  systolic  murmur  at  the  apex.  The  other  is  that  of  a  definite 
mitral  stenosis,  the  presystolic  murmur  beginning  now  to  assume 
its  typical  character.  The  two  types  may  be  combined.  Nodules 
are  less  common  than  at  an  earlier  age ;  arthritis  somewhat  more 
common. 

In  adults,  arthritis  is  usually  the  most  prominent  symptom,  and 
often  causes  much  suffering.  Many  joints  may  be  affected,  one  or 
two  leading  the  way,  and  others  becoming  involved  in  rapid 
succession.  The  distribution  of  the  arthritis  is  fairly,  but  not 
accurately,  symmetrical.  The  larger  joints,  especially  the  knees,  are 
most  affected,  but  the  smaller  joints  have  no  immunity.  The  synovial 
sacs,  where  the  structure  of  the  joint  allows  it,  become  distended 
with  fluid ;  this  is  most  marked  in  the  knees,  where  it  lifts  the 
patella  from  the  condyles  and  distends  the  suprapatellar  sac,  the 
normal  outline  of  the  joint  being  lost  in  a  rounded  swelling.  The 
skin  over  the  joint  is  generally  pale,  though  it  may  be  slightly 
hyperaemic.  The  tendon  sheaths  near  the  joint  may  also  be 
affected.  Movement  of  the  affected  joints  is  very  painful.  In 
slighter  cases,  the  inflammation  may  leave  the  joint  or  joints  first 
affected  and  appear  in  others. 

Sweating  may  be  general  and  profuse ;  it  often  causes  a  peculiar 
odour,  especially  when  the  patient  is  allowed  to  remain  in  an 
unchanged  flannel  night-dress.  Sudamina  and  miliaria  are  fre- 
quently caused  by  the  sweating.  Erythema  is  occasionally  seen  ; 
urticarial  and  purpuric  forms  of  eruption  are  rare  ^ ;  chorea  is  seldom 
met  with  in  adults,  nodules  still  more  rarely. 

The  urine  in  acute  rheumatism  is  scanty  and  of  high  specific 
gravity,  soon  becoming  turbid  with  urates,  and  occasionally  containing 

^  A  case  of  very  extensive  bullous  purpuric  erythema,  with  pericarditis  and  fatal 
myocarditis,  in  a  girl  of  seventeen  under  the  care  of  the  author,  is  reported  (with  an 
■account  of  the  autopsy  and  of  the  microscopical  examination  of  the  cardiac  muscle) 
by  Dr.  Poynton  in  the  Lancet,  Oct.  28,  1899. 


ACUTE   AND   SUBACUTE   RHEUMATISM  299 

a  trace  of  albumin.  The  tongue  is  often  furred.  Anemia  is 
rapidly  produced  by  rheumatism,  and  is  often  a  marked  feature  of 
the  disease. 

The  predominance  of  the  arthritis  in  adults  has  brought  it 
about  that  acute  rheumatism  has  been  classed  among  diseases  of  the 
joints,  and  that  the  far  more  important  cardiac  affections  have  been 
considered  as  "  complications."  How  essentially  erroneous  this 
view  is  a  careful  examination  of  the  heart  in  almost  any  case  of  acute 
or  subacute  rheumatism  will  show.  Even  in  a  subacute  case,  in 
which  there  is  very  slight  arthritis  and  hardly  any  pyrexia,  deter- 
mination of  the  so-called  "  deep  "  cardiac  dulness  by  careful  light 
percussion  will  almost  always  reveal  an  increase  in  size  of  the  heart, 
which  usually  diminishes  more  or  less  when  the  attack  is  over,  and 
sometimes  returns  to  the  normal.  Accompanying  this  evidence  of 
dilatation  there  is  generally  some  alteration  in  the  quality  of  the 
first  sound,  and  the  cardiac  impulse  is  diffused  and  feeble.^ 

These  facts  prove  that  the  arthritis  of  rheumatism  is  but  one 
manifestation  of  a  toxaemia,  in  which  the  central  organ  of  the  circu- 
lation is  almost  always  more  or  less  seriously  affected.  The  physician 
must  beware  of  being  satisfied  with  the  absence  of  murmur ;  the 
quality  of  the  first  sound  must  be  observed,  and  a  most  careful 
examination  of  the  heart,  by  percussion  and  palpation  as  well  as 
by  auscultation,  must  be  made  in  every  case.  An  acute  dilatation, 
whether  merely  toxic  or  due  to  definite  myocarditis,  is  a  serious 
matter,  and  calls  for  prolonged  rest  and  careful  treatment. 

Often  the  evidence  of  disease  of  the  heart  is  obtrusive,  even  on 
the  most  superficial  examination ;  but  it  is  by  no  means  easy  to 
decide  in  all  cases  whether,  or  how  far,  the  carditis  is  recent  or  of 
old  standing.  This  is  especially  true  with  regard  to  dilatation  and 
systolic  murmurs.  An  increase  of  dilatation  and  a  fresh  endocarditis 
may  very  probably  be  part  of  the  present  attack.  Fresh  pericarditis 
is  not  ver}^  common  in  adults,  and  in  them  it  is  usually  much  less 
serious  than  in  children,  but  an  adherent  pericardium  is  not 
uncommon.  It  cannot,  however,  be  diagnosed  unless  there  are  also 
external  adhesions  fixing  heart  and  pericardium  to  sternum,  pleurae, 
and  lungs.  It  is  probable  that  the  greater  part  of  the  embarrassment 
of  the  heart  usually  assigned  to  adherent  pericardium  is  due  to 
myocarditis,  old  or  recent,  and  increasing  dilatation. 

The  results  of  chronic  heart  disease  produced  by  previous  attacks 
of  rheumatism  often  add  enormously  to  the  danger  of  a  later  attack, 
and  ver)'  greatly  increase  the  difficulty  of  treatment.     When  chronic 

^  Vide  Med. -Chi.  Trans.  1898,  pp.  401-417. 


300  MANUAL  OF  MEDICINE 

dilatation,  mitral  stenosis,  or  aortic  regurgitation  has  existed  for  some 
years,  compensation  is  apt  to  break  down  readily  on  the  occurrence 
of  even  a  slight  fresh  rheumatism,  and  congestion  of  the  bases  of  the 
lungs,  with  indications  of  bronchitis  or  oedema,  dilatation  of  the  right 
heart,  enlargement  of  the  liver,  sometimes  dropsical  effusion  into 
the  serous  cavities  or  into  the  subcutaneous  tissue  of  the  lower  limbs 
and  of  the  loins,  may  manifest  themselves. 

The  lungs  and  their  serous  covering  suffer  much  less  in  rheuma- 
tism than  the  heart  and  pericardium.  Pleuritic  friction  sometimes 
occurs,  and  is  painful ;  but  there  is  rarely  much  fluid  effusion. 
Pneumonic  consolidation  of  lung  is  met  with  in  a  few  cases. 

The  temperature  in  rheumatism  is  variable.  In  a  large  propor- 
tion of  cases  it  is  comparatively  low,  not  exceeding  102°  F.,  often 
not  over  100°,  and  it  rapidly  falls  to  normal  under  treatment.  But 
even  with  this  very  moderate  pyrexia  acute  cardiac  dilatation  is 
usually  present,  and  severe  pericarditis  may  exist.  The  temperature 
chart  in  this  disease  furnishes  no  trustworthy  indication  of  the  extent 
of  the  damage  to  the  heart  which  is  being  produced.  Yet  there  is 
one  very  important  reason  why  it  should  be  closely  watched ;  in 
some  cases  the  temperature  rapidly  rises,  and  it  may  run  up  in  a  few 
hours  to  107°,  108°,  109°,  or  even  110°  F.  Death  may  quickly 
follow,  unless  some  method  of  cooling  the  patient  is  used  immedi- 
ately. As  hyperpyrexia  comes  on  there  is  usually  a  tendency  to 
delirium,  and  often  a  marked  subsidence  of  the  arthritis.  A  warning 
of  the  onset  of  this  grave  complication  is  frequently  to  be  found 
in  the  cessation  of  perspiration,  the  skin  becoming  hot  and  dry  in 
a  patient  who  had  been  previously  sweating  profusely.  Headache, 
sleeplessness,  and  restlessness  should  also  be  considered  as  warning 
symptoms.  Rheumatic  hyperpyrexia  hardly  ever  occurs  in  a 
child,  which  is  remarkable,  for  a  terminal  hyperpyrexia  is  by  no 
means  uncommon  in  some  cerebral  affections  in  infancy  and  early 
childhood.  Occasionally,  however,  a  case  of  chorea  may  end  in 
hyperpyrexia,  sometimes  preceded  by  distinct  rheumatic  symptoms, 
sometimes  alone. 

Symptoms  strongly  suggestive  of  meningitis,  such  as  strabismus, 
opisthotonos,  muscular  spasm,  and  final  coma  may  occur  in 
rheumatic  hyperpyrexia,  and  even  when  the  temperature  does  not 
exceed  104°,  but  actual  inflammation  of  the  cerebral  membranes 
is  very  seldom  found  post-mortem. 

The  arthritis  of  acute  or  subacute  rheumatism  usually  subsides 
completely  when  the  attack  comes  to  an  end,  which  may  occur 
spontaneously,  as  was  shown  in   the  cases  "treated"  with   mint- 


ACUTE  AND   SUBACUTE  RHEUMATISM         301 

water  in  the  presalicylic  days.  But  this  spontaneous  recovery  was 
often  very  slow,  as  indicated  by  the  well-known  story  of  the 
physician  who  was  asked  what  was  good  for  rheumatism,  and 
replied  "  six  weeks."  Those  who  remember  how  rheumatism 
behaved  before  the  introduction  of  salicylates  will  acknowledge 
that  this  was  no  great  exaggeration.  The  shortening  of  the  dura- 
tion of  a  rheumatic  attack  by  the  use  of  the  salicylates  is  marked 
and  unquestionable. 

But  it  must  be  added  that  the  subsidence  of  a  rheumatic 
arthritis,  treated  or  untreated,  is  not  always  complete.  Occasionally, 
in  what  seems  to  be  a  subacute  rheumatism  affecting  several  joints, 
one  joint  remains  swollen  and  painful  long  after  all  the  others  have 
recovered,  and  it  may  show  indications  of  structural  changes. 
Some  cases  of  this  kind  are  not  truly  rheumatic,  but  are  a  gonor- 
rhoea! arthritis ;  others  are  the  initial  stage  of  the  disease  known 
as  "chronic  rheumatoid  arthritis."  ^Mienever  "rheumatism" 
settles  down  into  a  chronic  arthritis  of  a  single  joint,  one  or  other 
of  the  above-named  diseases  should  be  suspected.  The  relation- 
ship of  true  rheumatism  to  "  chronic  rheumatism  "  affecting  many 
joints  and  crippling  them  with  fibroid  thickenings  of  ligaments 
and  tendons,  and  also  to  the  chronic  myalgias  of  later  life,  is  a 
subject  with  regard  to  which  further  precise  investigation  is  needed. 

Until  recently  acute  rheumatism  was  regarded  as  essentially 
an  arthritis,  and  the  painful,  tender,  swollen  joints,  the  acid  sweats, 
the  furred  tongue,  the  scanty  urine  loaded  with  urates,  and  the 
pyrexia,  were  thought  to  be  the  essentials  of  the  disease.  Pericarditis 
and  endocarditis  were  looked  upon  as  "complications."  But  when  the 
malady  was  carefully  studied  in  hospitals  for  children,  it  became 
evident  that  this  view  was  far  too  narrow,  that  in  early  life  arthritis 
is  a  comparatively  insignificant  part  of  the  disease,  and  that  the 
damage  to  the  heart  is  more  frequent  and  severe  than  in  adults, 
^lore  recently  it  has  been  shown  that  the  rheumatic  state  manifests 
itself  not  only  by  arthritic  and  cardiac  lesions,  but  also  by  various 
other  clinical  phenomena  formerly  regarded  as  complications,  or  as 
of  merely  accidental  occurrence.  In  opening  the  discussion  on 
"Rheumatism,  and  its  i\.llies  in  Childhood,"  at  the  meeting  of  the 
British  Medical  Association  in  1883,  Dr.  Barlow,  in  an  exhaustive 
paper,  showed  that  erythema  (and  occasionally  urticaria  and  pur- 
pura), stiff  neck,  slight  pains  referred  to  the  muscles,  tonsillitis, 
subcutaneous  nodules,  and  chorea  are  frequent  and  characteristic 
evidences  of  rheumatism  in  childhood.  Dr.  Cheadle  summed  up 
the  results  of  his  long  experience  at  the  Hospital  for  Sick  Children 


302  MANUAL  OF  MEDICINE 

in  lectures  on  "  Heart  Disease  in  Children,"  published  in  the 
Lancet  in  1885,  and  again  in  his  Harveian  lectures  (1888)  "On 
the  Various  Manifestations  of  the  Rheumatic  State,  as  exemplified 
in  Childhood  and  Early  Life,"  in  both  of  which  he  emphasised  the 
importance  of  these  non-articular  evidences  of  rheumatism  in  child- 
hood, and  showed  how  the  various  members  of  the  "rheumatic 
series "  may  occur  in  varying  sequence  and  combination.  He 
also  insisted  on  the  frequency  and  importance  of  an  inherited 
predisposition  to  rheumatic  disease,  and  pointed  out  that  evidence 
of  such  inheritance,  combined  with  the  presence  of  some  of  the 
non-articular  manifestations  of  rheumatism,  is  sufficient  to  prove 
the  rheumatic  origin  of  many  cases  of  heart  disease  in  which  no 
history  of  arthritis  can  be  obtained.  The  late  Dr.  Sturges,  in  his 
Lumleian  lectures  in  1894,  laid  great  stress  on  the  cardiac  inflam- 
mation caused  by  rheumatism  in  children,  and  on  the  high  mortality 
thence  resulting.  When  it  was  observed  that  in  rheumatism  there 
is  usually,  if  not  invariably,  an  acute  dilatation  of  the  heart,  even  in 
subacute  cases  with  trifling  pyrexia  and  slight  symptoms,  it  became 
evident  that  the  most  important  part  of  this  malady  is  its  toxic 
action  on  the  heart,  and  the  resulting  inflammatory  condition  of 
this  organ. 

Pathology. — The  true  nature  and  origin  of  this  disease  are  still 
unknown ;  but  the  facts  already  stated  make  it  certain  that  no 
neurotic  theory  and  no  theory  of  perverted  metabolism  can  fully 
account  for  the  phenomena  :  these  strongly  suggest  a  microbic  infec- 
tion. The  greater  frequency  and  greater  virulence  of  rheumatism 
in  childhood  remind  the  physician  of  the  infectious  fevers,  and  the 
occasional  occurrence  of  sore  throat  and  of  a  characteristic  eruption, 
with  the  pyrexia,  are  other  points  of  resemblance.  In  its  ill-defined 
course  it  resembles  tuberculosis.  In  its  tendency  to  produce  acute 
dilatation  of  the  heart  it  resembles  influenza.  The  arthritis  of 
rheumatism  is  very  closely  simulated  by  the  arthritis  produced  by 
the  gonococcus.  No  microbe  has  yet  been  proved  to  be  the 
cause  of  rheumatism  ;  but  the  same  is  true  of  such  undoubtedly 
microbic  diseases  as  measles,  scarlet  fever,  whooping-cough,  and 
syphilis.  The  strongly-marked  hereditary  predisposition  to  rheuma- 
tism causes  no  difficulty,  for  the  same  fact  is  observed  in  tuberculosis. 
That  exposure  to  cold  and  wet  is  often  a  factor  in  the  causation  of 
a  rheumatic  attack  is  analogous  to  what  is  often  observed  in 
pneumonia. 

Rheumatism  has  a  certain  relation  to  season,  the  maximum 
number  of  cases  in  London  occurring  in  October  and  November. 


ACUTE   AND   SUBACUTE   RHEUMATISM  303 

It  is  also  more  prevalent  in  some  years  than  in  others.  For  an 
elaborate  analysis  of  the  available  statistics  on  this  subject  reference 
may  be  made  to  Dr.  Newsholme's  "  Milroy  Lectures."  ^  The  times 
of  greater  prevalence  are  probably  times  when  the  conditions  of 
temperature  and  moisture  of  the  soil  are  specially  favourable  to 
the  development  of  certain  microbes. 

It  seems  not  unlikely  that  rheumatism  may  be  a  house  disease, 
the  germs  being  endemic  in  damp,  ill-drained  dwellings,  extending 
upwards  along  damp  walls,  or  being  carried  by  air-currents  from  the 
soil.  It  would  be  interesting  to  inquire  whether  the  disease  ever 
occurs  in  houses  with  impermeable  basement. 

Recurrences  of  rheumatism  may  be  fresh  infections,  or  they  may 
be  caused  by  renewed  activity  of  germs  lying  dormant  in  some  part 
of  the  human  organism,  as  occurs  with  regard  to  tubercle.  As  the 
pneumococcus  may  be  found  in  the  saliva  of  many  persons  who  have 
suffered  from  pneumonia,  so  the  rheumatic  microbe  may  be  lurking 
somewhere  in  the  patient  who  has  had  rheumatic  fever.  As  a  man 
who  has  been  infected  with  syphilis  is  always  syphilitic,  so  a  patient 
who  has  once  suffered  from  rheumatism  may  be  permanently 
rheumatic,  and  the  temporary  diminution  of  his  power  of  resistance 
by  a  chill  may  suffice  to  produce  a  second  attack. 

It  should  be  noted  that  rheumatism  does  not  excite  suppuration  ; 
the  inflammatory  effusions  which  it  causes  are  all  of  the  fibro-serous 
type.  If  suppuration  occurs  in  a  joint  believed  to  be  affected  with 
rheumatic  inflammation,  either  the  diagnosis  is  erroneous  or  a  mixed 
infection  has  taken  place. 

It  has  long  been  known  that  rheumatism  produces  a  disastrous 
effect  on  the  heart,  and  that  endocarditis  and  pericarditis  are 
frequent  results ;  but  far  too  little  attention  has  been  paid  to  the 
condition  of  the  cardiac  muscle,  and  a  careful  investigation  of  this, 
by  the  most  recent  histological  methods,  is  greatly  needed.  In  four 
recent  fatal  cases  Dr.  Poynton  found  (along  with  plastic  pericarditis) 
very  definite  myocarditis ;  loss  of  striation  with  much  fatty  degener- 
ation of  the  cardiac  muscular  fibres,  and  dilated  capillaries  with 
numerous  foci  of  small  cells  in  the  interstitial  tissue,  not  merely  near 
the  pericardium,  but  also  throughout  the  entire  thickness  of  the  cardiac 
wall.  These  observations  suggest  that  rheumatic  myocarditis  is 
not  due  simply  to  extension  from  an  inflamed  pericardium  or 
endocardium,  but  is  a  primary  lesion.  If  this  be  so,  it  is  a  fact  of 
the  greatest  importance.  It  seems  probable  that  the  damage  to 
the  muscular  substance  of  the  heart  is  the  true  explanation  of  the 

^  Lancet,  1895. 


304  MANUAL  OF  MEDICINE 

destructive  action  of  rheumatism.  It  is  easy  to  understand  how  the 
injury  to  the  cardiac  muscular  wall  reveals  itself  clinically  in  an  acute 
dilatation,  a  condition  which  often  remains  as  a  permanent  chronic 
dilatation,  and  becomes  the  most  important  element  in  the  cardiac 
failure  of  chronic  heart  disease.  It  is,  however,  by  no  means  certain 
that  an  actual  myocarditis  is  present  in  the  cases  which  recover,  and 
especially  in  those  of  slight  intensity.  The  dilatation  observed  in 
subacute  cases  may  possibly  be  due  to  a  minor  degree  of  toxic 
action  on  the  muscle  without  myocarditis.  In  an  investigation 
published  in  the  third  volvLxne^  o{  \.\\q  Physiological /ourtial  {iZ?>o), 
Dr.  Gaskell  found  that  a  dilute  solution  of  lactic  acid  (i  in  10,000) 
produced  marked  dilatation  in  the  frog's  ventricle,  and  also  in  its 
arterioles,  while  a  dilute  solution  of  sodium  hydrate  caused  contrac- 
tion of  both.  He  found  that  some  drugs  acted  like  lactic  acid, 
others  like  sodium. 

It  has  long  been  suspected,  though  on  insufficient  grounds,  that 
lactic  acid  is  the  poisonous  element  in  rheumatism,  and  Dr.  Gaskell's 
observations  indicate  that  it  would  produce  the  acute  dilatation 
which  actually  occurs.  But  it  seems  more  probable  that  the  poison 
is  a  toxine  produced  by  a  microbe,  and  that  the  poisoning  of  the 
tissues  in  rheumatism  is  a  selective  action  of  this  toxine,  analogous 
to  the  selective  action  of  the  toxines  of  diphtheria  and  of  tetanus. 

Since  endocarditis  and  dilatation  are  so  characteristic  of  the 
rheumatic  heart,  great  doubt  must  be  felt  as  to  the  rheumatic 
origin  of  cases  in  which  the  pericardium  is  found  to  be  entirely 
adherent  and  greatly  thickened,  with  extensive  mediastinal  ad- 
hesions, but  where  the  valves  are  normal,  and  the  heart  is  small. 
One  case  of  this  kind  recently  examined  post-mortem  at  the  Hospital 
for  Sick  Children  was  found  to  be  of  tuberculous  nature. 

Prognosis. — A  rheumatic  attack  in  a  child  is  much  more  serious 
than  in  an  adult.  In  early  life  the  mortality  from  cardiac  rheuma- 
tism is  very  considerable.  The  prognosis  as  to  life  or  death  in  such 
an  attack  must  be  mainly  founded  on  a  careful  examination  of  the 
heart,  especially  with  regard  to  its  size  and  strength.  The  important 
points  are:  (i)  The  amount  of  cardiac  dilatation ;  (2)  the  strength 
and  localisation,  or  the  feebleness  and  diffusion  of  the  impulse  ;  and 
(3)  the  presence  or  absence  of  pericarditis.  Endocarditis  has  but 
little  bearing  on  the  immediate  prognosis,  unless  it  be  of  the  malig- 
nant variety,  which  is  rare  at  this  age.  Mitral  stenosis  and  aortic 
regurgitation  are  seldom  so  advanced  in  a  child  that  they  can  to  any 
great  extent  influence  the  prognosis  as  to  recovery. 

The  condition  of  the  heart  when  acute  rheumatism  has  subsided 


ACUTE  AND  SUBACUTE  RHEUMATISM         305 

is  of  great  Importance  as  the  basis  of  an  opinion  as  to  the  limitation 
of  life  or  of  capacity  for  active  exertion  which  will  result.  But  the 
most  careful  estimate  is  only  too  likely  to  be  falsified  by  the  occur- 
rence of  another  attack  of  rheumatism,  involving  increased  injury  to 
the  heart.  It  must,  therefore,  be  constantly  borne  in  mind  that 
evidence  of  an  active  rheumatic  toxaemia  is  of  the  greatest  importance 
from  the  point  of  view  of  prognosis,  and  that  such  evidence  is  by 
no  means  limited  to  the  question  of  arthritis,  but  that  it  may  be 
manifested  by  sore  throat,  erythema,  rheumatic  nodules,  chorea, 
pleurisy,  pericarditis,  endocarditis,  and  especially  by  acute  dilatation 
of  the  heart.^  After  two  or  three  such  attacks,  very  great  dilatation 
may  be  produced,  and  pericarditis,  then  supervening,  may  rapidly 
cause  death. 

In  adolescents  there  is  less  likelihood  of  a  fatal  result  from  a 
rheumatic  attack ;  but  the  presence  of  valvular  disease  (mitral 
regurgitation,  mitral  stenosis,  less  commonly  aortic  regurgitation) 
makes  the  prognosis  more  serious.  Marked  cardiac  dilatation,  and 
adhesion  of  the  pericardium,  both  to  the  heart  and  to  the  sternum, 
pleurae,  and  lungs,  increase  greatly  its  gravity.  The  least  hopeful 
cases  are  those  in  which  there  is  much  dilatation,  with  a  loud 
systolic  apex  murmur,  and  evidence  of  external  pericardial  adhesions: 
such  patients  rarely  survive  to  adult  life.  The  most  hopeful  are 
those  in  which  dilatation  is  slight,  external  pericardial  adhesions 
absent,  and  a  mitral  systolic  the  only  murmur :  such  cases  may 
have  permanent  compensation  and  live  for  many  years,  some  even 
to  old  age.  Mitral  stenosis  of  high  degree  is  of  evil  prognosis, 
especially  if  the  right  heart  is  more  dilated  than  hypertrophied, 
and  the  liver  has  become  enlarged.  Mitral  stenosis  of  low  degree 
with  efficient  compensation  may  permit  the  patient  to  live  to  forty 
years,  in  a  few  instances  even  longer.  The  great  majority  of  the 
cases  of  mitral  stenosis  in  which  no  history  of  rheumatism  or 
chorea  can  be  obtained  are  almost  certainly  the  result  of  a  slight, 
perhaps  relapsing,  rheumatic  endocarditis  which  escaped  observation 
because  pain  and  arthritis  were  absent  or  so  slight  as  to  have  been 
entirely  forgotten.  Mitral  stenosis  is  probably  never  of  congenital 
origin  ;  it  would  be  safe  to  assert  that  no  one  has  ever  heard  a 
presystolic  murmur  in  a  baby. 

In  adults  a  rheumatic  attack  is  not  often  directly  fatal,  unless  the 
heart  is  already  much  diseased,  or  hyperpyrexia  supervene.  The 
patient  will  almost  certainly  survive ;  but  his  future  condition   will 

1   It  must  not  be  inferred  from  this  statement  that  rheumatism  is  the  only  cause 
of  acute  dilatation  of  the  heart  in  a  child. 

VOL.  I  X 


3o6  MANUAL  OF   MEDICINE 

depend  to  a  great  extent  on  the  amount  of  the  injury  to  the  heart. 
The  mechanical  effects  of  damaged  valves  will  assert  themselves  as 
time  passes,  but  the  chronic  dilatation  is  in  itself  a  factor  of  great 
importance.  And  in  adults  also,  though  less  frequently  than  in 
children,  the  pernicious  effect  of  a  fresh  rheumatism  may  some- 
times be  seen,  entirely  altering  the  prognosis  previously  formed. 

Treatment. — Complete  rest  in  bed  is  the  first  essential ;  this 
must  be  insisted  on,  even  in  the  slightest  cases,  especially  in  children 
and  adolescents,  and  the  practitioner  must  not  allow  himself  to  be 
misled  by  the  trivial  nature  of  the  arthritis.  The  condition  of  the 
heart  must  be  at  once  ascertained,  its  exact  size  defined  by  careful 
light  percussion,  the  position  and  character  of  the  cardiac  impulse 
noted,  the  quality  of  its  sounds,  and  of  any  murmurs  present 
observed.  The  temperature  must  be  taken,  and  a  chart  at  once 
instituted.  For  a  rheumatic  patient,  a  mattress  is  better  than 
a  feather  bed,  and  cotton  sheets  are  preferable  to  linen.  The 
patient  should  be  protected  from  draughts.  Where  there  is  much 
sweating,  a  flannel  jacket  should  be  worn  over  the  night-dress,  and 
the  latter  should  be  changed  as  required.  In  the  severer  cases 
the  assistance  of  a  trained  nurse,  strong  enough  to  lift  the  patient, 
is  necessary.  The  diet  should  at  first  consist  of  milk  and  beef-tea 
only.  If  constipation  is  present,  a  laxative  may  be  administered ; 
but  active  purgation  should  be  avoided.  If  there  is  no  constipation, 
a  single  lo-grain  dose  of  pulvis  ipecacuanhae  co.  may  be  given  (to 
adults)  for  the  relief  of  pain,  and  it  may  sometimes  be  repeated 
with  advantage. 

Sodium  salicylate  should  be  given  immediately,  in  doses  propor- 
tioned to  the  age  :  to  children,  about  three-fourths  of  a  grain  for  each 
year,  to  adults  in  doses  of  20  grains.  This  drug  appears  to  be 
as  definitely  antagonistic  to  the  rheumatic  process  as  mercury  to  the 
syphilitic  or  quinine  to  the  malarial.  With  the  salicylate  it  is  useful 
to  give  sodium  bicarbonate,  in  a  dose  twice  as  large  as  that  of  the 
salicylate.  The  medicine  should  be  taken  hourly  for  the  first  three 
hours,  afterwards  every  three  hours,  during  the  day-time ;  during  the 
night  also,  if  the  patient  is  awake.  When  the  temperature  has  fallen 
to  99°  F.,  and  the  joint-pains  have  subsided,  the  frequency  may  be 
reduced  to  thrice  daily,  and  this  should  be  continued  for  a  week  or 
ten  days  after  the  pains  have  disappeared.  Too  early  discontinuance 
of  the  salicylate  is  very  often  followed  by  a  relapse  of  the  symptoms 
— clear  evidence  of  the  power  of  the  remedy.  Necessity  for  reducing 
the  dose  of  salicylate  is  indicated  by  deafness  and  tinnitus,  sometimes 
by  vomiting,  occasionally  by  delirium,  and  in  a  few  cases  by  irregu- 


ACUTE  AND  SUBACUTE  RHEUMATISM         307 

larity  of  pulse.  If  any  of  these  symptoms  are  present,  smaller  doses 
of  the  salicylate  should  be  given ;  but  it  should  not  be  omitted 
altogether,  if  this  can  possibly  be  avoided.  Care,  however,  should 
be  taken  to  ensure  that  the  drug  used  is  of  good  quality,  and  free 
from  adulteration. 

It  is  thought  by  some  physicians  that  salicylate  is  depressing  to 
the  heart ;  probably  a  large  part  of  the  cardiac  depression  supposed 
to  be  produced  by  the  drug  is  really  caused  by  the  action  of  the 
rheumatic  poison,  leading  to  toxic  dilatation  and  myocarditis, 
especially  in  hearts  already  damaged  by  previous  rheumatism,  and 
suffering  from  chronic  dilatation  or  serious  valvular  disease.  No 
doubt  some  patients  are  specially  susceptible  to  the  action  of  salicylate 
as  others  are  to  that  of  quinine  or  of  morphine ;  but  as  a  rule,  in  the 
earlier  attacks  of  rheumatism  the  doses  above  mentioned  may  be 
given  without  fear  of  bad  effects.  If  it  seems  necessary  to  omit  the 
salicylate,  salicin  may  be  substituted ;  but  it  must  be  given  in  larger 
doses  (30  to  40  grains  for  adults),  or  quinine  may  be  given  with 
alkalies  in  an  effervescent  mixture.  Occasionally  a  small  dose  of 
calomel  may  be  useful. 

The  joints  should  be  wrapped  in  cotton  wool  and  kept  at  rest. 
Only  when  an  arthritis  tends  to  become  chronic  should  counter- 
irritation  be  used,  by  small  blisters  or  a  moderately  strong  iodine 
solution  applied  in  the  neighbourhood  of  the  joint.  Small  doses  of 
potassium  iodide  may  be  of  service  for  chronic  pains  about  the 
joints. 

The  heart  must  be  carefully  examined  every  day.  If  pericardial 
friction  become  audible,  an  ice-bag  should  at  once  be  applied  over 
the  precordial  region.  The  ice-bag  must  be  water-tight,  with  an 
accurately-fitting  screw  top  ;  it  should  rest  directly  on  the  skin,  and 
should  be  surrounded  with  cotton  wool  or  a  soft  towel  to  absorb  the 
moisture  which  condenses  on  its  outer  surface.  The  area  to  which 
it  is  to  be  applied  should  be  outlined  on  the  skin,  and  the  nurse 
must  see  that  its  position  does  not  become  shifted  when  the  patient 
moves.  If  there  is  much  tenderness,  the  ice-bag  may  be  suspended 
so  as  to  just  touch  the  skin,  but  after  a  few  hours  it  will  be  possible 
to  apply  it  thoroughly.  For  young  children  hot-water  bottles  must 
previously  be  placed  in  the  bed,  so  as  to  keep  the  feet  and  legs  quite 
warm  ;  the  temperature  should  also  be  taken  every  half-hour  at  first. 
If  pericarditis  is  present  when  the  case  comes  under  observation, 
and  there  is  much  cardiac  dilatation,  it  will  be  wise  to  apply  leeches 
before  having  recourse  to  the  ice.  The  use  of  the  salicylate  is  not 
to  be  omitted  on  account  of  pericarditis.     In  first  attacks  of  rheu- 


3og  Manual  of  medicine 

matism  it  is  usually  possible  to  keep  the  ice-bag  continuously  in 
position  ;  but  in  later  attacks,  when  there  is  much  dilatation  present, 
it  must  be  removed  at  intervals.  It  may  be  applied  for  two  or  for 
three  hours,  removed  for  one  hour  or  for  two,  then  reapplied,  in 
accordance  with  the  condition  of  each  case.  Sometimes  it  is  better 
to  omit  it  altogether  during  the  night ;  but  it  is  desirable  that  the 
application  of  the  bag  should  be  as  persistent  as  possible.  In  many 
cases  it  may  be  applied  for  a  week  or  ten  days,  or  even  longer,  with 
great  benefit  to  the  patient.  It  is  probable  that  the  local  use  of  ice 
not  merely  controls  the  pericarditis,  but  that  it  also  tends  to  check 
myocarditis,  and  it  may  sometimes  be  used  with  benefit  for  the 
latter  purpose  in  a  rheumatic  attack  in  which  there  is  acute  dilatation 
but  no  pericarditis.  Whether  its  influence  extends  as  deeply  as 
the  endocardium  is  doubtful ;  but  we  have  no  other  means  of 
arresting  endocarditis.  If  pericarditis  is  accompanied  by  pleurisy 
or  pneumonia,  an  additional  ice-bag  should  be  placed  over  the  in- 
flamed lung  or  pleura,  and  the  strain  on  the  right  side  of  the  heart 
should  be  relieved  by  the  application  of  leeches  over  the  liver. 

If  ice  cannot  be  obtained,  small  doses  of  opium  or  hypodermic 
morphine  are  advisable  to  quiet  the  distress,  and  leeches  should  be 
applied  over  the  heart.  It  is  uncertain  whether  blisters  are  of  any 
real  service  in  the  treatment  of  pericarditis,  and  they  greatly  impede 
the  examination  of  the  heart. 

Surgical  measures  are  never  necessary  in  rheumatic  pericarditis, 
and  they  are  extremely  dangerous  on  account  of  the  great  cardiac 
dilatation.  In  suppurative  pericarditis,  on  the  other  hand,  they  are 
urgently  necessary,  and  may  save  life. 

In  the  later  attacks  of  rheumatism,  when  there  is  tumultuous 
action  of  the  heart,  great  dilatation,  and  much  cardiac  distress,  opium 
or  morphine,  in  small  doses,  often  gives  great  relief.  This  may  be 
followed  by  digitalis ;  but  it  must  be  clearly  recognised  that  the 
mere  presence  of  a  murmur  is  not  to  be  taken  as  a  signal  for  the 
employment  of  this  drug. 

If  the  temperature  is  persistently  high  and  rising,  especially  if,  at 
the  same  time,  the  arthritis  subsides  and  the  skin  becomes  dry,  the 
temperature  must  be  taken  every  half-hour.  When  it  reaches  105°  F., 
the  patient  should  be  sponged  with  cold  water  and  covered  only  with 
a  sheet ;  if  this  is  insufficient  to  arrest  the  rise,  decided  measures 
must  be  taken  at  once.  When  a  bath  can  be  obtained,  and  the 
patient  is  not  too  heavy,  it  may  be  filled  with  water  at  80°  and  the 
patient  immersed  in  it  for  fifteen  or  twenty  minutes,  the  water  being 
meanwhile  cooled  to  60^  by  the  addition  of  lumps  of  ice.      During 


ACUTE   AND   SUBACUTE   RHEUM ATIS.AI  309 

this  time  his  temperature  should  be  frequently  taken  by  a  ther- 
mometer in  the  mouth  ;  as  soon  as  this  reaches  102  ,  he  should  be 
taken  out  of  the  bath,  replaced  in  bed,  and  covered  with  one  blanket, 
with  a  hot  bottle  to  his  feet.  The  temperature  wnll  fall  2'  or  3'' 
further  after  his  removal  from  the  bath.  The  procedure  must  be 
repeated  as  often  as  necessary.  It  is  sometimes  more  convenient 
to  cover  the  bed  mth  a  large  Mackintosh  sheet,  and  to  lay  the 
patient  absolutely  naked  upon  it,  sousing  him  all  over  with  ice-cold 
water  or  rubbing  him  with  lumps  of  ice.  The  temperature  in  the 
mouth  must  be  frequently  taken  during  this  process. 

Prolonged  rest  in  bed  is  of  the  greatest  importance  after  a  rheu- 
matic attack,  especially  if  pericarditis,  fresh  endocarditis,  or  much 
acute  dilatation  has  occurred.  In  such  cases  it  is  well  to  keep  the 
patient  in  bed  for  an  entire  month  after  the  temperature  has  become 
normal.  The  tendency  to  relapse  is  best  averted  by  administering 
one  or  two  daily  doses  of  the  salicylate  for  three  or  four  weeks  \  in 
some  cases  it  is  needed  for  an  even  longer  period.  Provided  this 
be  done,  it  is  safe  and  useful  to  prescribe  iron  for  the  anaemia,  the 
best  preparation  being  the  dialysed  solution  of  iron,  given  in  drachm 
doses  (to  adults),  in  glycerine  and  water,  after  meals.  If  the  heart 
has  suffered  damage,  gentle  "resistance-movements,"  repeated  once 
or  twice  daily,  should  be  practised  for  two  or  three  weeks  before 
any  active  exertion  is  allowed. 

Children  who  have  suffered  from  rheumatism,  especially  if  any 
injury  to  the  heart  has  been  caused  by  it,  need  careful  regulation  of 
their  life  both  at  home  and  at  school.  The  danger  of  a  second 
attack,  which  will  almost  certainly  cripple  the  heart  still  more,  must 
always  be  kept  in  mind  by  the  physician, 

D.  B.  Lees. 


3IO  MANUAL  OF  MEDICINE 

CHICKEN-POX 

Syn.  Water-pock,  Glass-pock,  Varicella 

Chicken-pox  is  an  infectious,  though  usually  mild,  febrile  dis- 
order, attended  with  an  eruption  of  papules,  which,  for  the  most 
part,  rapidly  develop  into  characteristic  vesicles.  These,  after  a 
few  days,  dry  up  and  form  scabs,  which  ultimately  separate,  and 
sometimes  leave  behind  more  or  less  persistent  scarring  of  the  skin. 

Although  the  disease  was  described  by  Ingrassia  as  far  back  as 
the  year  1550,  it  was  not  until  the  latter  half  of  the  eighteenth 
century  that  its  specific  distinctions  from  smallpox  were  clearly 
recognised ;  and  even  since,  the  two  affections  have  often  been 
confused.  The  prevalence  of  chicken-pox  seems  to  be  regulated 
by  no  known  influences.  Neither  season  nor  climate  appear  to 
be  operative.  The  association  of  susceptible  persons  with  one 
suffering  from  the  disease,  and  this  under  circumstances  favourable 
to  personal  contact,  are  the  only  conditions  which  are  known  to  be 
concerned  in  its  diffusion. 

Susceptibihty  to  infection  varies  with  the  state  of  a  person's 
general  health,  and  whether  or  no  he  has  had  a  previous  attack. 
Chicken-pox  is  particularly  Hable  to  attack  a  child  recently  con- 
valescent, or  while  actually  suffering,  from  scarlet  fever,  measles,  or 
diphtheria,  if  accidentally  exposed  to  infection.  The  protection 
conferred  by  an  attack  is  probably  more  complete  than  it  is  in  the 
case  of  any  other  infectious  fever,  with  the  possible  exception  of 
whooping-cough.  A  second  attack  of  chicken-pox  is  extremely 
rare,  although  an  instance  is  recorded  in  which  a  person  was  three 
times  attacked  with  the  disease.  Age  does  not  appear  to  exert 
much  influence,  though  the  large  proportion  of  attacks  occur 
between  the  second  and  fifth  years  of  life.  The  disease  is  rarely 
seen  in  adults,  probably  because  most  grown-up  persons  have 
already  suffered  from  the  disease  in  their  childhood.  Both  sexes 
are  attacked  indiscriminately.  The  infection  of  chicken-pox 
does  not  seem  to  be  readily  conveyed  indirectly.  The  disease, 
however,  frequently  arises  in  a  sporadic  fashion,  it  being  quite 
impossible  to  trace  any  connection  with  a  previous  case.  Its 
inoculability  is  doubtful. 

The  length  of  incubation   in   chicken-pox  in   the   large   pro- 


CHICKEN-POX  3 1 1 

portion  of  attacks  varies  between  the  limits  of  thirteen  to  fifteen 
days,  but  it  may  be  as  short  as  ten,  or  as  long  as  nineteen.  A 
quarantine  of  twenty  days  should  be  insisted  on. 

Symptoms. — An  attack  of  chicken-pox  may  be  either  7nild  or 
severe,  the  severity  of  the  attack  being  commonly  proportionate 
to  the  amount  of  the  eruption ;  in  other  words,  to  the  number  of 
the  pocks. 

In  some  attacks  the  eruption  is  the  first  symptom  of  the 
disease,  but  frequently  the  child  may  be  noticed  to  be  fretful  and 
its  temperature  slightly  raised  for  a  few  hours  before  the  rash 
comes  out.  Occasionally,  conjunctival  injection  or  an  er}'thematous 
flush  on  the  trunk  may  be  noted  as  well.  This  pre-eruptive  stage 
is  rarely  of  twenty-four  hours'  duration,  but  in  adults  the  symptoms 
may  be  really  severe,  in  which  case  pain  in  the  back,  shivering, 
headache,  and  weariness,  attended,  perhaps,  ttdth  a  temperature  of 
102°,  or  even  more,  may  be  present  for  two  clear  days  before  the 
eruption  declares  itself.  In  such  instances  the  invasion  closely 
simulates  that  of  smallpox,  and  the  rash  as  a  rule  is  copious. 

The  chicken-pox  eruptio?t  comes  out  in  successive  crops  of 
slightly  raised  pinkish-red  papules  of  variable  size,  most  of  which 
in  a  few  hours  become  converted  into  characteristic  thin-walled, 
limpid,  glistening  vesicles.  Some  of  these  develop  so  rapidly  that 
the  papular  stage  may  escape  observation,  in  which  case  the 
vesicles  resemble  little  delicate  blisters,  such  as  might  develop  on 
the  skin  as  the  result  of  drops  of  scalding  water.  Others  are 
obviously  situated  upon  a  red,  injected,  and  slightly  raised  base, 
the  central  portion  of  which  alone  may  have  become  vesicular. 
Some  of  the  papules,  especially  the  smaller  ones,  never  develop 
into  vesicles  at  all,  but  remain  as  small  red,  acuminate,  or  irregularly 
pyramidal  pimples  until  they  fade  away.  At  the  ver}-  earliest 
stage  the  papules  appear  as  small,  round,  or  ovoid  spots,  which, 
before  becoming  ob\-iously  raised,  can  be  felt  as  slight  points  of 
thickening  in  the  superficial  layers  of  the  skin.  The  individual 
pocks  reach  their  full  development  at  about  the  end  of  two  days, 
after  which  the  contents  of  the  vesicles  become  turbid.  They 
then  rapidly  shrink  and  dry  up,  forming  brownish,  horny-looking 
scabs,  which  usually  separate  at  the  end  of  a  week  or  ten  days. 
A  slight  areola  can,  as  a  rule,  be  seen  around  the  base  of  the  fully 
developed  vesicle,  which  is  sometimes,  though  usually  not,  um- 
bilicated.  If  the  vesicle  be  pricked,  a  thin  clear  fluid  readily 
escapes,  and  the  walls  entirely  collapse  under  pressure  with  the 
finger,  though   a  slight  thickening  of  the  skin  at  its  base  is  still 


312  MANUAL  OF  MEDICINE 

clearly  distinguishable.  The  contents  of  some  of  the  vesicles 
when  fully  developed  may  become  purulent,  in  which  case  the 
areola  is  more  pronounced,  and  a  more  or  less  permanent  depressed 
cicatrix  remains  after  the  scab  has  become  detached.  Suppuration 
of  the  pock  invariably  results  if  it  be  scratched  or  otherwise 
ruptured,  and  this  most  often  occurs  on  the  face  and  scalp. 

The  eruption,  perhaps  oftener  than  not,  comes  out  earlier  on 
the  trunk  than  elsewhere,  but  spots  may  appear  first  on  the  face 
and  scalp,  or  even,  though  far  more  rarely,  on  the  limbs.  Ulti- 
mately the  whole  surface  of  the  skin  may  be  invaded,  but  it  is 
usual  for  the  eruption  to  be  relatively  more  copious  on  the  trunk, 
thighs,  and  upper  arms  than  the  face,  scalp,  or  extremities.  It  is 
not  common  for  the  palms  or  soles  to  be  affected,  unless  the  rash 
be  fairly  extensive,  and  even  then  the  spots  may  never  get  beyond 
the  papular  stage. 

The  mucous  membranes  may  also  be  invaded,  especially  those 
of  the  palate,  tongue,  and  buccal  surface  of  the  cheek.  No  true 
vesicle  is  found,  however,  but  the  pock  is  represented  by  a  white 
sodden-looking  papule,  which  usually  breaks  down  into  a  shallow 
ulcer,  and  then  rapidly  heals.  Pocks  occur,  moreover,  though  far 
more  rarely,  on  the  conjunctivae  and  the  mucous  surface  of  the 
genitals.  A  pecuUarity  of  the  chicken-pox  eruption  is  that  it  comes 
out  in  several  crops,  perhaps  three  or  four,  commonly  on  succeeding 
days ;  or  an  interval  of  a  day  or  two  may  elapse  between  two  con- 
secutive crops.  Hence  it  is  that  the  length  of  the  stage  during  which 
the  eruption  is  coming  out  is  commonly  three  to  five  days,  though 
sometimes  longer.  The  writer  has  seen  it  extend  in  one  instance 
to  ten  days,  and  even  longer  periods  have  been  recorded.  The 
total  number  of  pocks  may  vary  from  half  a  dozen  or  so  up  to 
several  hundred.  MacCombie  states  that  the  number  is  frequently 
from  fifty  to  two  hundred.  The  aggregate  number  of  pocks  will 
depend  upon  the  number  of  crops,  and  may  be  taken  as  a  measure 
of  the  duration  and  of  the  general  severity  of  the  attack. 

The  appearance  of  each  crop  of  spots  is  commonly  attended 
with  a  rise  of  temperature,  perhaps  to  ioo°,  or  102°;  sometimes 
higher.  The  temperature  usually  falls  in  the  interval,  if  not  to  the 
normal,  to  something  very  near  it.  The  second  exacerbation  is 
usually  the  highest,  and  a  few  pocks  can  then  generally  be  seen  on 
the  mucous  membranes,  the  subsequent  ones,  should  there  be  any, 
becoming  gradually  less  pronounced.  The  pyrexia  of  chicken-pox, 
then,  is  an  irregular  one,  and  if  prolonged,  shows  wide  daily  varia- 
tion.    In  some  cases,  especially  when  the  rash  is  sparse  and  com- 


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314  MANUAL  OF   MEDICINE 

prised  in  a  single  crop,  the  temperature  remains  normal  throughout. 
Some  acceleration  of  pulse  accompanies  the  pyrexia,  and  the  tongue 
is  usually  lightly  furred.  The  eruption  may  lead  to  slight  enlarge- 
ment of  the  lymphatic  glands  adjacent  to  any  of  the  pocks  which 
have  suppurated,  and  is  often  attended  with  considerable  itching 
and  consequent  irritability  of  temper  in  young  children. 

In  rare  instances  some  of  the  vesicles  are  inordinately  developed, 
and  form  distinct  bullae  of  varying  size.  They  may  even  attain  the 
size  of  a  hen's  egg,  in  which  case  a  raw  denuded  surface  of  corre- 
sponding area  remains  after  the  fluid  is  let  out.  The  condition 
closely  resembles  pemphigus,  and  is  sometimes  described  as  a 
variety  of  chicken-pox  under  the  name  of  vmicella  bullosa.  Attacks 
of  chicken-pox  are  occasionally  met  with  in  which  a  necrotic  change 
occurs  in  the  skin  forming  the  base  of  the  pock.  K  certain  number 
only  are  affected  in  most  instances,  but  in  some,  almost  all  of 
them  undergo  the  same  change.  The  attack  begins  in  the  ordinary 
way,  but  as  the  case  proceeds,  the  inflammatory  areola  surrounding 
an  affected  pock  gets  larger  and  more  intense,  and  the  vesicle  is 
converted  into  a  dark  brownish,  and  ultimately,  black  scab,  which 
gradually  becomes  thickened  and  enlarged  so  as  to  resemble  a 
rupial  crust.  The  underlying  skin  is  found  to  have  become 
gangrenous,  and  from  its  margin  a  thin  sanious  or  blood-stained  dis- 
charge escapes.  After  the  slough  has  separated  a  clearly  defined 
punched-out  ulcer  remains,  which  may  extend  superficially  or  in 
depth,  and  lead  to  a  considerable  loss  of  tissue.  In  fatal  cases  the 
temperature  remains  elevated,  emaciation  becomes  pronounced, 
and  the  patient  gradually  sinks.  The  condition  is  known  as  vari- 
cella gangrenosa,  and  is  usually  fatal ;  but  if  a  few  pocks  only  are 
affected,  recovery  will  probably  ensue.  Occasionally  in  these 
severe  attacks  an  effusion  of  blood  into  the  skin  at  the  base  of  the 
pocks  and  from  some  of  the  mucous  membranes  has  been  re- 
corded, a  condition  to  which  the  term  varicella  Juzmorrhagica  has 
been  applied. 

The  only  complication  worth  recording  is  a  condition  of 
impetiginous  eczema,  which  sometimes  supervenes,  probably  as  the 
result  of  dirt  or  scratching,  although  various  affections  have  been 
observed  to  arise  shortly  after  chicken-pox,  such  as  nephritis,  pneu- 
monia, bronchitis,  hemiplegia,  and  paraplegia  ;  their  connection  with 
the  disease  is  very  much  open  to  doubt. 

Bacteriology. — No  micro-organism  has  yet  been  satisfactorily 
established  as  the  specific  infecting  agent.  Both  staphylococci  and 
streptococci  occur  in  the  vesicles,  as  they  do  in  those  of  smallpox 


CHICKEN-POX  315 

and  vaccinia,  and  a  bacillus  which  normally  inhabits  the  epidermis. 
Protozoa  and  an  oval  coccus  have  been  described,  and  Bareggi  of 
Milan  claims  to  have  isolated  the  latter  and  by  its  injection  to  have 
successfully  communicated  the  disease  to  children. 

No  morbid  changes  in  the  viscera  special  to  varicella  are 
known  ;  nor  does  the  disease  ever  seem  to  be  fatal,  except  in  the 
gangrenous  or  hsemorrhagic  forms.  In  the  former  variety,  which  is 
probably  determined  rather  by  the  constitutional  predisposition  of 
the  particular  patient  than  by  any  augmentation  in  the  virulence  of 
the  specific  contagion,  the  gravity  is  proportionate  to  the  number 
of  pocks  affected. 

The  differential  diagnosis  of  chicken-pox  and  modified  small- 
pox is  fully  discussed  in  connection  with  the  latter  disease  (p.  324), 
but  the  importance  of  the  following  points  justifies  their  special 
mention. 

In  chicken-pox,  pocks  in  all  stages  of  development,  macule, 
papule,  vesicle,  pustule,  and  scab,  can  often  be  seen  side  by  side 
within  a  restricted  area.  In  chicken-pox  a  tense,  fully  developed 
vesicle  may  be  found  at  a  spot  on  which  twenty  -  four  hours 
previously  not  even  the  suggestion  of  a  papule  could  be  detected. 
Second  attacks  of  chicken-pox  are  so  exceptional,  that  the  diagnostic 
value  of  a  few  scars  in  a  doubtful  attack  can  hardly  be  over- 
estimated. Concerning  the  nature  of  such  scars,  it  is  rare  at  the 
present  day  in  this  country  to  find  a  person  bearing  the  marks  of 
antecedent  smallpox,  especially  if  well  vaccinated  ;  moreover  the 
cicatrices  of  variola  are  usually  more  abundant  on  the  face  than 
elsewhere,  whereas  in  chicken-pox  the  reverse  obtains. 

A  case  of  varicella  bullosa  may  closely  simulate  pemphigus,  but 
the  presence  of  one  or  more  normal  pocks  associated  with  the 
bullae  will  decide  its  real  nature. 

The  treatment  of  simple  varicella  is  comprised  in  the  pre- 
vention of  the  patient  from  scratching  his  pocks.  In  the  gan- 
grenous form  the  administration  of  stimulants  and  a  generous 
diet  will  be  necessary,  and  the  affected  pocks  should  be  dressed 
with  warm  boracic  fomentations.  The  patient  should  be  isolated 
until  all  the  scabs  have  separated.  This  usually  means  a  detention 
of  from  two  to  three  weeks. 

F.  FooRD  Caiger. 


3i6  MANUAL  OF  MEDICINE 


SMALLPOX 
Syn.  Variola 

Smallpox  is  an  acute,  specific,  contagious  disorder,  characterised 
by  pyrexia  and  by  the  appearance,  after  a  definite  period  of  incuba- 
tion, of  an  eruption  which  passes  through  the  successive  phases  of 
papule,  vesicle,  and  pustule. 

Smallpox  affects  all  races,  every  age,  and  both  sexes.  In 
countries  in  which  smallpox  has  been  prevalent  for  generations  it 
was,  prior  to  the  introduction  of  vaccination,  a  disease  of  early 
childhood,  owing  to  the  fact  that  practically  all  the  adults  would 
have  previously  passed  through  the  disease.  In  vaccinated  com- 
munities this  incidence  of  the  disease  is  no  longer  found  to  persist. 
Smallpox  is  not  limited  to  any  particular  portion  of  the  globe, 
although  it  is  apt  to  be  more  severe  in  warm  climates.  It  has 
usually  been  especially  virulent  on  its  first  introduction  into  any 
country,  as  an  instance  of  which  may  be  cited  an  epidemic  which 
occurred  in  Iceland  in  1 707-1 709,  from  which  about  one-third  of 
the  total  population  died. 

Seasonal  prevalence.  —  In  England  and  other  temperate 
climates  smallpox  is  apt  to  be  most  prevalent  in  spring,  autumn, 
and  winter,  comparatively  few  cases  being  met  with  in  the  summer. 
MacCombie  states  that  he  has  frequently  noticed  that  in  outbreaks 
commencing  in  autumn,  there  has  been  a  sudden  drop  in  June  the 
following  year,  and  that  the  lessened  incidence  prevailed  during  the 
summer  months.  But  he  does  not  consider  it  probable  that  this 
drop  is  mainly  due,  as  has  been  suggested,  to  the  more  open-air 
habits  of  life  in  summer. 

Mode  of  conveyance. — Smallpox  infection  may  be  either 
direct  or  indirect,  and  it  has  recently  been  shown  by  Mr.  Power 
and  others  that  the  contagium  may  be  carried  for  a  considerable 
distance  through  the  air  from  a  smallpox  hospital,  especially  at 
times  when  the  latter  contains  a  number  of  acute  cases.  Most 
frequently,  however,  a  previously  healthy  person  becomes  infected 
through  close  contact  with  a  patient  suffering  from  the  disease. 
Cases  of  smallpox  must  be  considered  as  infectious  from  the  eariiest 
onset  of  the  disease,  although  the  danger  is  probably  greater  after 
the  appearance  of  the  eruption,  and  perhaps  especially  so  when  the 


SMALLPOX 


317 


crusts  are  commencing  to  separate.  The  bodies  of  persons  who 
have  died  of  smallpox  are  also  capable  of  conveying  the  disease, 
though  it  may  be  that  actual  contact  is  necessary  in  this  case.  In- 
fection is  also  n  jt  unfrequently  conveyed  by  articles  of  personal  use, 
such  as  clothing,  bedding,  and  the  like,  even  after  considerable 
intervals  of  time,  during  which  they  may  have  been  stored,  and 
outbreaks  have  occasionally  occurred  in  paper-mills  from  the  use  of 
infected  rags  in  the  manufacture  of  paper.  It  is  also  possible  that 
healthy  persons,  who  have  been  in  contact  with  the  sick,  may 
convey  the  disease  to  others  by  means  of  their  clothing  or  hair. 


Seasonal  Curve  of  Smallpox  Mortality  (London), 
Mean  of  40  Years. 


Jan. 

1 

Feb. 

March 

April 

May 

June 

July 

Aug. 

Sept. 

Oct 

Nov. 

Dec. 

/ 

^ 

s 

^ 

•^ 

^^ 

^ 

^ 

^ 

^ 

\ 

-/- 

\ 

^^ 

\ 

^ 

^ 

y^ 

\ 

^ 

y 

y 

^ 

Each  division  corresponds  to  lo  per  cent  above  or  below  the  mean  annual  mortality  indicated  by 

dotted  line. 

An  individual  is  only  to  be  considered  as  free  from  the  liability  to 
transmit  variola  "  when  every  scab  has  fallen  off  and  the  skin 
lesions  have  all  healed "  (Medical  Officers  of  Schools,  Code  of 
Rules). 

Incubation. — The  period  which  may  elapse  after  exposure  to 
infection,  by  which  alone  smallpox  in  the  present  day  is  con- 
tracted, and  before  any  definite  symptoms  pointing  to  invasion  of 
the  system  by  the  disease  becomes  obvious,  has  been  variously 
estimated,  but  in  the  great  majority  of  cases  is  found  to  be,  as 
nearly  as  possible,  twelve  days.  The  Code  enjoins  an  isolation  for 
sixteen  days  after  exposure  to  infection  and  thorough  disinfection 
at  the  commencement  of  the  period. 


3i8  MANUAL  OF  MEDICINE 

Symptoms  and  progress. — During  the  incubation  stage  of 
smallpox  it  is  exceptional  for  any  definite  symptoms  to  present 
themselves,  although  occasionally  the  patient  may  complain  of  a 
feeling  of  languor  and  general  malaise.  The  appearance  of  the 
typical  eruption  is  preceded  for  about  a  couple  of  days  by  certain 
well-marked  symptoms,  commencing  with  a  somewhat  sudden  and 
often  rapid  rise  of  temperature,  ushered  in  with  chills  or  actual 
rigors,  or,  in  children,  convulsions.  In  adults  especially,  heat  and 
perspiration  of  the  skin  may  be  profuse,  and  anorexia,  thirst,  and 
constipation  well  marked,  together  with  a  feeling  of  nausea,  or  actual 
vomiting.  In  children  constipation  is  liable  to  be  replaced  by 
diarrhoea.  Symptoms  pointing  to  invasion  of  the  nervous  system 
usually  present  themselves  early  in  the  progress  of  the  disease,  of 
which  acute  lumbar  pain  is  at  once  the  most  typical  and  constant. 
Headache  and  aching  of  the  limbs  are  often  complained  of,  together 
with  drowsiness,  which  may  pass  into  stupor  and  coma.  On  the 
other  hand,  delirium  not  unfrequently  supervenes,  occasionally 
developing  into  a  maniacal  condition.  The  symptoms  of  this 
stage  are  severe  in  proportion  to  the  severity  of  the  attack  which  they 
usher  in.  Other  things  being  equal,  therefore,  the  higher  the 
temperature,  the  more  persistent  the  vomiting,  the  acuter  the  pain 
in  the  back,  and  the  more  pronounced  the  implication  of  the  brain, 
the  more  quickly  will  the  disease  assume  grave  proportions,  and  the 
greater  will  be  its  intensity  and  the  prospect  of  a  fatal  issue. 

By  about  the  third  day  these  prodromal  symptoms  will  attain 
their  maximum,  and  the  eniption  typical  of  the  disease  appears. 
The  rash  commences  as  minute  reddish  papules,  which  are  distinctly 
hard,  giving  a  "  shotty  "  sensation  when  the  finger  is  passed  over  the 
skin.  These  are  first  found,  and  in  greatest  numbers,  on  those 
parts  of  the  body  which  are  ordinarily  uncovered,  more  particularly 
the  face,  head,  neck,  and  wrists.  During  the  next  two  days  the 
chest,  abdomen,  and  upper  and  lower  extremities  become  invaded, 
though  to  a  less  extent.  The  papules  gradually  enlarge,  and  in 
the  course  of  two  or  three  days  become  converted  into  vesicles. 
About  three  days  later  the  vesicular  contents,  at  first  limpid,  will 
have  become  purulent.  The  resulting  pustule  increases  in  size, 
and  becomes  surrounded  by  a  dark  red  zone  of  inflammation, 
termed  the  "areola."  The  inflammation,  together  with  the  swell- 
ing of  the  underlying  tissues  due  to  inflammatory  exudation,  still 
further  increases  up  to  about  the  ninth  day  (eleventh  day  of  the 
disease),  or  even  a  day  or  two  later  in  the  case  of  that  portion  of  the 
eruption  on  the  lower  part  of  the  trunk  and  extremities.     When  the 


SMALLPOX  319 

eruption  is  somewhat  scanty,  the  separate  pocks  on  the  face  remain- 
ing distinctly  isolated  from  one  another,  the  attack  is  said  to  be 
of  the  discrete  variety,  the  papules  in  this  form  of  the  disease  not 
unfrequently  showing  a  crescentic  arrangement  in  their  grouping.  If, 
on  the  other  hand,  the  pocks  are  so  numerous  as  to  coalesce  with 
one  another,  the  disease  is  said  to  be  of  the  cotiflue?it  form.  In 
certain  specially  severe  cases,  the  so-called  hcBt7iorrhagic  smallpox,  the 
contents  of  the  pocks  at  quite  an  early  stage  are  found  to  be  mixed 
with  blood,  while  in  a  still  severer  form  of  the  disease,  7?ialig?iant 
smallpox,  minute  punctiform  hsemorrhages  become  visible  at  an 
early  stage  just  beneath  the  surface  of  the  skin,  the  patient  probably 
dying  collapsed  before  the  appearance  of  the  typical  eruption. 

Although  most  obvious  on  the  skin,  the  rash  of  smallpox  is  by  no 
means  confined  to  the  outer  surface  of  the  body.  It  not  unfrequently 
develops  to  a  considerable  extent  on  the  mucous  membrane  of  the 
mouth,  nose,  and  throat,  and  even  that  of  the  larynx  and  trachea, 
and  of  the  conjunctiva. 

Prodromal  rashes.  —  The  eruption  typical  of  the  disease  is 
occasionally  preceded  for  a  day  or  two  by  rashes  bearing  somewhat 
of  a  resemblance  to  those  which  occur  in  measles  and  scarlet  fever. 
This  is  not  unfrequently  so  in  smallpox  which  has  been  modified  by 
antecedent  vaccination.  Again,  in  cases  which  eventually  prove  to 
be  of  severe  type  an  abundant  rash  either  of  somewhat  similar 
character  or  of  a  hasmorrhagic  nature  is  apt  to  occur,  more  particularly 
on  the  lower  portion  of  the  abdomen,  where  it  usually  occupies  an 
area  between  the  umbilicus  and  the  pubes  similar  in  outline  to  an 
inverted  triangle,  and  also  to  a  less  extent  on  the  chest  and  loins. 

Specially  characteristic  of  the  disease  is  the  fact  that  on  the  first 
appearance  of  the  eruption  all  the  symptoms  from  which  the  patient 
will  previously  have  been  suffering  become  ameliorated.  To  so 
great  a  degree  is  this  the  case,  that  in  the  milder  form  of  the 
disease  the  patient  may  believe  himself  to  have  recovered,  and 
persist  in  going  about  his  ordinary  avocations.  Owing  to  this  fact 
the  disease  is  often  spread  by  the  peregrinations  of  tramps  from 
town  to  town. 

Although  in  an  ordinar}'  attack  of  smallpox  the  typical 
symptoms  will  thus  in  large  measure  have  disappeared  on  the 
outbreak  of  the  eruption,  this  latter  will  itself  in  all  probability 
cause  some  inconvenience  to  the  patient,  as  will  also  soreness  of  the 
mouth  and  tongue,  which  are  likely  to  be  accompanied  with 
ptyalism.  Owing  to  the  eruption  affecting  to  some  extent  the 
upper    part    of  the   alimentary   and    respiratory   tracts,    the   throat 


320  MANUAL  OF  MEDICINE 

becomes  painful  and  the  voice  hoarse,  while  the  patient  is  often 
troubled  with  a  harsh  cough.  In  severe  cases  laryngeal  com- 
plications are  usually  present  from  an  early  stage. 

The  after  course  of  the  disease  will  vary  considerably  in  accord- 
ance with  the  severity  or  reverse  of  the  attack.  In  the  mildest 
cases  the  vesicles  never  become  really  pustular,  commencing  to 
contract  and  dry  up  before  this  stage  is  reached.  In  such  cases 
the  temperature,  which  will  have  fallen  almost  or  quite  to  normal 
on  the  appearance  of  the  eruption,  does  not  again  appreciably  rise, 
and  the  patient  speedily  becomes  convalescent.  Ordinarily,  however, 
after  a  period  of  apparent  convalescence  extending  to  about  the 
eighth  or  ninth  day  of  the  disease  the  maturation  of  the  pustules  is 
ushered  in  by  a  period  of  secondary  fever,  accompanied,  it  may  be, 
by  chills  or  rigors  and  a  rise  of  temperature  as  high  as,  or  even 
exceeding  that  reached  at  the  commencement  of  the  disease.  The 
pulse  is  quickened,  anorexia  again  presents  itself,  and  the  patient  may 
become  delirious.  In  the  confluent  form  of  the  disease  little  or  no 
appreciable  remission  of  symptoms  accompanies  the  appearance  of 
the  eruption,  although  the  temperature  may  perhaps  fall  a  degree  or 
so.  Almost  immediately,  however,  it  mounts  again,  and  both  febrile 
and  nervous  symptoms  rapidly  become  aggravated,  attaining  their 
maximum  severity  at  about  the  period  of  maturation  of  the 
pustules. 

If  the  course  of  the  temperature  be  noted  in  a  typical  attack  of 
the  disease,  it  will  be  found  to  rise  rapidly  during  the  stage  of  in- 
vasion, it  may  be  to  104°,  or  even  106°.  As  previously  stated,  it 
usually  falls  to  a  considerable  extent  coincidently  with  the  appear- 
ance of  the  eruption,  although  for  the  most  part  not  descending 
quite  to  the  normal  level.  As  the  contents  of  the  vesicles  become 
purulent  the  temperature  once  more  rises  to  102°,  7:03°,  or  even 
104°,  while  in  cases  tending  to  a  fatal  termination  this  range  may  be 
exceeded  by  two  or  three  degrees. 

The  delirimn,  which  is  so  marked  a  symptom,  more  particularly 
of  the  severer  cases,  like  the  temperature,  may  show  a  temporary  re- 
mission after  the  eruptive  stage,  reappearing  once  more,  and  even 
in  a  severer  form,  with  the  occurrence  of  the  secondary  fever.  In 
sorjie  cases  the  patient,  already  delirious,  may  become  violently 
maniacal. 

'YYvQ.  pulse  becomes  increased  with  the  rise  of  fever,  falls  together 
with  the  temperature  after  the  appearance  of  the  eruption  and  again 
quickens  with  the  period  of  secondary  fever.  Respiratio7i  also  be- 
comes more  or  less  hurried  in  correspondence  with  similar  variations 


SMALLPOX  321 

in  the  pulse  rate.  In  severe  confluent  cases  the  breathing  is  apt  to 
become  shallow  and  laboured. 

The  urine  is  febrile  in  character.  During  the  pustular  stage  of 
the  disease  the  amount  of  urea  excreted  is  markedly  increased,  and 
albuminuria  has  been  found  to  occur  in  about  one-third  of  the  total 
number  of  cases.      Haematuria  is  rare. 

Thirst  h  a  marked  feature  throughout,  and  in  the  milder  forms 
of  the  disease  perspiratmis  persist  from  first  to  last,  except  in  the 
case  of  children.  In  confluent  smallpox,  however,  perspirations  are 
exceptional,  while  salivation  is  a  common  and  troublesome  symptom. 
In  such  cases,  on  account  of  the  swollen  condition  of  both  mucous 
tnembrane  and  skin,  the  mouth  cannot  be  closed,  while,  owing  to  the 
sweUing  of  the  eyelids,  it  is  difficult  or  impossible  to  open  the  eyes. 
The  nose,  ears,  and  lips  also  may  become  so  enormously  swollen  as 
to  render  the  patient  unrecognisable,  even  to  his  relatives.  The 
extremities  in  like  manner  are  often  so  oedematous  and  painful  that 
even  the  weight  of  the  bed-clothes  can  hardly  be  endured. 

Within  three  or  four  days  from  the  commencement  of  the 
pustular  phase  of  the  eruption,  by  which  time  the  secondary  fever 
in  favourable  cases  will  have  practically  subsided,  the  pustules  will 
either  dry  up,  forming  for  the  most  part  flattened,  reddish-brown 
scales,  or  they  become  ruptured,  their  contents  escape,  and,  drying 
up,  dark-coloured,  thick,  adherent  crusts  result.  Most  typical  of 
this  stage  is  a  peculiar  fetid  odour,  which  has  been  likened  to  the 
smell  of  mice,  exhaled  from  the  skin. 

The  swelling  of  the  skin  now  subsiding,  the  features  return  more 
or  less  to  their  previous  appearance,  and  during  the  third  week  of 
the  disease  the  "crusts"  commence  to  separate,  but,  owing  to  the 
occasional  formation  and  separation  of  successive  "crusts,"  the  re- 
sulting sores  may  not  be  completely  healed  for  another  week  or  more. 

From  this  period  onwards,  in  favourable  cases,  rapid  progress 
towards  convalescence  may  be  expected,  although  even  in  the 
milder  cases  there  is  a  possibility  that  certain  complications  and 
sequelce  may  intervene. 

Complications  and  sequelae. — An  attack  of  smallpox  is 
liable  to  be  followed  by  various  sequelae,  whether  the  attack  itself  be 
mild  or  severe,  although  serious  complications  more  commonly 
manifest  themselves  after  the  confluent  form  of  the  disease ;  of 
these  perhaps  the  most  common  is  ery'sipelas,  particularly  of  the 
face  and  head,  together  with  boils,  and  probably,  later  on,  abscesses, 
both  subcutaneous  and  deep-seated,  which  may  attain  a  large  size 
and  heal  with  difficulty.      Otitis  and  coiijunctivitis  may  be  met  with, 

VOL.  I  Y 


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SMALLPOX  323 

ophthalmia  occasionally  ensuing  in  consequence  of  the  formation 
of  pustules  on  the  conjunctiva.  These  never  occur  on  the  cornea 
itself,  although  a  form  of  ulceration  which  is  apt  to  extend  slowly 
from  one  side  of  the  cornea  to  the  other  is  occasionally  observed. 

Other  possible  complications  include  bronchitis,  broncho-pneumonia, 
and  pleurisy  ;  paralysis  of  the  extretnities  or  bladder  has  been  observed. 

As  the  result  of  the  destruction  of  the  cutis  vera,  which  will  be 
more  or  less  extensive  according  to  the  amount  of  the  original 
eruption,  indelible  cicatrices  will  be  left ;  the  face  specially,  after  a 
severe  confluent  attack,  often  remaining  scarred  and  seamed  in  all 
directions.  The  ophthalmia,  to  which  reference  has  already  been 
made,  may  result  in  permanent  blindness.  Permanent  alopecia 
only  occurs  after  severe  attacks,  and  chiefly  in  adults.  Unless  the 
follicles  have  been  destroyed,  regeneration  of  hair,  which  may  have 
been  shed  during  the  course  of  the  disease,  takes  place  rapidly  and 
abundantly  after  recovery. 

Morbid  anatomy  and  histology. — Except  in  severe  hsemor- 
rhagic  cases,  in  which  blood  will  be  found  effused  into  the  substance 
of  the  solid  viscera,  and  beneath  the  serous  and  mucous  surfaces, 
no  special  appearances  are  likely  to  be  observed  on  post-mortem 
examination. 

Comparatively  little  is  known  as  to  the  actual  histological 
changes  occurring  in  the  skin  in  smallpox  during  the  development 
of  the  eruption,  there  appearing  to  be  no  record  of  any  continuous 
study  of  the  minute  anatomy  of  this  disease.  So  far  as  can  be 
judged  from  such  examination  as  has  been  made  of  the  micro- 
scopical structure  of  the  skin  at  various  stages  of  the  eruption, 
there  would  appear  to  be  a  complete  similarity  with  those  observed 
during  the  eruption  of  vaccina,  for  an  account  of  which  reference 
may  be  made  to  the  article  dealing  with  this  disease.  The  same 
article  may  also  be  consulted  for  a  brief  account  of  the  bacteriology 
of  these  maladies. 

Modified  Smallpox  or  Varioloid  is  that  form  of  the  disease 
which  is  met  with  in  persons  who,  at  some  time  previous  to  their 
attack,  have  been  vaccinated,  but  in  whom  the  protection  afforded 
by  the  operation  has  been  insufficient,  either  from  the  vaccination 
having  been  imperfectly  performed  in  the  first  instance,  or  because 
its  effect  has  diminished  through  lapse  of  time. 

No  definite  rule  can  be  laid  down  as  to  the  extent  to  which  any 
one  symptom  or  set  of  symptoms,  are  likely  to  be  modified  as  the 
result  of  previous  vaccination,  but  for  the  most  part  the  case  re- 
sembles a  mild  form  of  the  discrete  variety.     Thus  the  disease  may 


324  MANUAL  OF  MEDICINE 

be  exceedingly  mild  from  the  commencement,  and  the  eruption 
may  be  absent  or  be  limited  to  the  appearance  of  a  few  papules  on 
the  face  or  hands.  Or  the  attack  may  commence  with  fairly  high 
fever,  generally,  however,  of  short  duration,  accompanied  by  severe 
headache,  lumbar  pain  and  vomiting,  only  to  abort  soon  after,  or 
even  before,  the  appearance  of  the  eruption.  If  an  eruption  ■  does 
present  itself  it  usually  does  not  develop  beyond  the  vesicular  or 
possibly  the  papular  stage,  and  secondary  fever,  if  it  supervenes,  is 
comparatively  slight.  It  is  in  cases  of  modified  smallpox  that 
generalised  prodromal  rashes  resembling  those  of  measles  or  scarlet 
fever  are  most  often  observed.  It  is  rare  for  a  case  of  modified 
smallpox  to  have  a  fatal  termination. 

Diagnosis. — The  diseases  from  which  smallpox  is  most  likely 
to  be  with  difficulty  distinguished  are  : — 

In  t/ie  initial  stages,  measles,  scarlet  fever,  syphilis,  and  the  rashes 
which  occasionally  appear  as  the  result  of  the  administration  of 
antitoxin  or  the  bromides. 

In  the  later  stages  the  discrete  or  modified  variety  may  simulate 
chicken-pox  or  acne. 

If  an  initial  rash  should  present  a  difficulty,  the  appearance  of 
the  typical  rash  will  probably  render  the  diagnosis  certain.  The 
diagnosis  of  modified  smallpox  from  chicken-pox,  however,  de- 
serves more  detailed  description. 

Differential  diagnosis  of  modified  smallpox  and  chicken- 
pox. — A  well-developed  attack  of  natural  smallpox  could  hardly  be 
mistaken  for  varicella,  but  in  respect  to  the  modified  disease,  especi- 
ally with  a  sparse  eruption,  the  diagnosis  may  present  considerable 
difficulty.  Careful  attention  to  the  following  points,  however,  will 
usually  serve  to  dispel  any  doubt  as  to  the  nature  of  the  case. 

{a)  In  modified  smallpox  the  eruption,  however  scanty,  is 
almost  invariably  preceded  by  severe  febrile  symptoms  of  two  days' 
duration.  In  varicella  this  prodronial  illness,  except  very  occasion- 
ally in  adults,  is  wanting.  The  rash  is  usually  the  first  sign,  pre- 
ceded possibly  for  a  few  hours  by  a  feeling  of  malaise. 

{b)  In  variola  the  eruption,  whatever  its  amount,  will  all  be 
visible  within  thirty-six  to  forty-eight  hours  of  its  first  appearance  \ 
but  in  varicella  the  eruption  usually  comes  out  in  distinct  crops, 
extending  over  a  period  of  three  to  five  days,  or  more. 

ic)  The  teftiperature  in  variola  falls  rapidly,  immediately  the 
eruption  appears,  whereas  in  varicella  each  crop  is  commonly 
attended  with  a  fresh  rise  of  temperature. 

(^)  Although  in  most  cases  of  modified  smallpox  the  vesicles 


SMALLPOX  325 

are  not  fully  formed  until  the  third  or  fourth  day  of  the  rash,  in- 
stances are  occasionally  seen  in  which  some  of  the  papules  show  an 
attempt  at  vesiculation  within  twenty-four  hours  of  their  first  appear- 
ance. The  presence,  however,  of  one  single,  well-developed,  tense 
vesicle  by  the  end  of  the  first  day  is  practically  sufficient  to  exclude 
variola,  though  common  enough  in  varicella,  especially  on  the  trunk 
and  thighs. 

{e)  The  vesicle  of  variola  usually  shows  more  induration  of  its 
base,  and  collapses  less  readily  when  pricked  than  does  the  vesicle 
of  varicella. 

(/)  In  variola  the  pocks  situated  within  a  circumscribed  area, 
being  for  the  most  part  of  the  same  age,  attain  coincidently  the 
same  degree  of  development,  whereas  in  varicella,  owing  to  the 
eruption  commonly  appearing  in  successive  crops,  pocks  in  all 
stages  of  development — from  papule  to  scab — may  often  be  de- 
tected side  by  side. 

{g)  The  relative  distribution  of  the  eri/ption  varies ;  in  variola  it  is 
apt  to  be  more  copious  on  the  face  and  extremities,  whereas  in  vari- 
cella it  is  usually  most  prevalent  on  the  trunk,  upper  arms,  and  thighs. 

Valuable  confirmatory  evidence  may  be  gleaned  from  a  history 
of  exposure  and  infection,  or  by  the  discovery  of  scars  indicative  of 
vaccination,  or  of  previous  varicella.  The  presence  of  the  latter  is 
almost  sufficient  to  exclude  chicken-pox,  so  excessively  rare  is  a 
second  attack,  while  in  a  child  the  presence  of  good  vaccination 
scars  will  similarly  tend  to  exclude  smallpox.  Chicken-pox  in  an 
adult  is  probably  as  rare  as  smallpox  in  a  well  -  vaccinated  child. 
Additional  evidence  may  be  gained  by  vaccinating  the  patient  and 
observing  what  result,  if  any,  follows  the  operation. 

Treatment. — To  Sydenham  we  owe  the  indications  for  the 
treatment  of  smallpox,  which  is  in  use  at  the  present  day.  He  first 
insisted  on  the  absolute  necessity  of  keeping  the  patient  cool,  while 
avoiding  chills,  this  being  attained  by  thorough  ventilation  of  the 
bed-chamber,  which  should  at  the  same  time  be  kept  at  as  equable 
a  temperature  (about  6o''  F.)  as  possible. 

No  medicinal  treatment  appears  to  be  of  avail  in  cutting 
short  the  course  of  the  disease,  although  the  various  symptoms 
and  complications  should  receive  appropriate  treatment  as  they 
arise.  The  comfort  of  the  patient  will  be  increased  by  the 
free  administration  of  cooling  drinks,  such  as  lemonade,  soda- 
water  and  milk,  or  toast  and  water,  while  at  the  same  time 
some  sahne  or  acid  medicine  may  be  given.  If  the  mouth 
be  sore  some  rehef  may  be  obtained   by  allowing  the  patient  to 


326  MANUAL  OF  MEDICINE 

suck  black-currant  jelly,  or  by  painting  it  with  a  solution  of  boro- 
glyceride,  while  if  there  be  much  discharge  from  the  nose  and 
throat,  a  solution  of  some  mild  antiseptic,  such  as  boracic  acid  or 
permanganate  of  potash,  will  be  found  of  service  as  a  wash.  If 
either  constipation  or  diarrhoea  be  present,  they  must  be  treated 
with  suitable  remedies.  The  drug  most  likely  to  be  of  service  in 
this  disease  is  opium,  since  it  is  valuable  both  for  the  relief  of  the 
delirium  and  of  the  severe  pain  which  is  commonly  present  during 
the  period  of  invasion.  It  is  equally  serviceable  during  the  second- 
ary phase  of  the  disease.  In  severe  cases  the  tendency  to  collapse 
should  be  combated  by  the  administration  of  ammonia,  and  of 
alcoholic  stimulants,  such  as  brandy  or  champagne.  The  patient 
should  be  placed  on  the  ordinary  fever  diet,  consisting  for  the  most 
part  of  milk  and  slops.  Even  in  the  milder  cases  of  the  disease 
much  discomfort  is  liable  to  be  caused  by  swelling  and  irritation  of 
the  skin,  which  may  be  considerably  relieved  by  frequent  sponging 
with  tepid  water,  followed  by  inunction  of  the  skin  with  carbolised 
oil  or  vaseline.  The  eyes  should  receive  particular  attention,  being 
carefully  sponged  at  frequent  intervals,  whilst  instillation  of  a  weak 
solution  of  nitrate  of  silver  (gr.  i.  to  water  5vi.)  will  be  advisable  if 
there  be  any  tendency  to  inflammation  of  the  conjunctiva. 

From  the  earliest  times  innumerable  plans  have  been  suggested 
for  the  prevention  of  the  pitting  of  the  skin,  which,  especially  after 
recovery  from  severe  attacks  of  the  disease,  is  liable  to  cause  great 
disfigurement.  It  is,  however,  very  doubtful  whether  such  pitting 
can  be  prevented  by  any  means  at  our  command ; — that  perhaps 
which  is  most  likely  to  have  the  desired  effect  being  the  evacuation 
of  the  contents  of  the  pock  as  soon  as  the  presence  of  fluid  can  be 
detected.  During  convalescence  it  is  of  the  utmost  importance  that 
the  patient's  strength  should  be  supported  by  the  administration  of 
tonic  remedies  together  with  stimulants  and  a  generous  diet. 

The  success  which  has  already  attended  the  method  of  serum- 
therapy,  more  particularly  in  diphtheria,  has  led  to  the  hope  that  a 
similar  method  may  presently  be  available  for  the  treatment  of 
smallpox,  but  thus  far  the  object  in  view  has  not  been  attained. 

As  regards  the  prevention  of  this  disease  we  have  in  efficient 
vaccination  and  revaccination  a  prophylactic  method  of  the  utmost 
value.     This  subject,  however,  will  be  treated  of  in  a  separate  section. 

Smallpox  Inoculation. — By  the  term  inoculation  is  meant  the 
purposeful  implantation  of  smallpox  virus  beneath  the  surface  of  the 
skin  in  the  same  manner  in  which  vaccination  is  now  carried  out, 


SMALLPOX  327 

The  origin  of  this  procedure  is  unknown,  although  undoubtedly 
it  has  been  practised  by  the  Chinese  and  Hindoos  for  centuries. 
From  them  it  extended  westwards  into  European  Turkey,  whence  it 
was  brought  to  England  in  1 721  by  Lady  Mary  Wortley  Montagu, 
the  wife  of  the  then  English  Ambassador  to  the  Ottoman  Court. 

The  insertion  of  smallpox  lymph  beneath  the  skin  was  followed 
by  a  series  of  events  very  similar  to  those  arising  from  vaccination. 
The  mature  vesicle,  however,  had  a  more  irregular  outline  than  the 
vaccine  vesicle,  and  was  usually  surrounded  by  a  number  of  tiny 
secondary  vesicles,  many  of  which  eventually  merged  into  the 
primary  one.  Occasionally,  as  in  the  mild  inoculations  carried  out 
at  the  commencement  of  the  present  century  by  two  brothers  of  the 
name  of  Sutton  and  by  Adams,  no  other  result  followed  than  the 
appearance  of  the  vesicle,  or  vesicles,  at  the  site  of  operation. 
Oftener,  however,  between  the  eighth  and  tenth  days  after  the  in- 
oculation a  general  eruption  followed,  which  might  be  limited  to  a 
few  vesicles  on  the  forehead,  or  might  result  in  a  copious  outbreak 
involving  almost  every  portion  of  the  body.  During  the  last  century 
the  risk  of  any  individual  contracting  smallpox  was  felt  to  be  so 
great  that  people,  while  still  in  good  health,  were  ready  to  run  the 
risk  of  purposely  contracting  the  disease,  in  what  was  usually  under 
these  circumstances  a  mild  form,  in  order  to  avoid  the  grave  danger 
to  life  which  was  inseparable  from  the  disease  contracted  in  the 
ordinary  manner.  The  process  of  inoculation  was  certainly  of 
value  to  those  individuals  on  whom  it  was  carried  out,  since, 
although  a  certain  number  of  these  contracted  the  disease  in 
severe  form  and  even  died  of  it,  yet  the  death-rate  was  in  all  prob- 
ability no  more  than  one  in  three  hundred  of  those  operated  on, 
whereas  that  of  ordinary  smallpox  was  apt  to  be  as  high  as  fifty 
per  cent.  Although  this  was  so,  the  practice  of  inoculation,  by 
carrying  smallpox  into  remote  districts  where  otherwise  it  might 
not  have  penetrated,  and  owing  to  the  fact  that  inoculated  small- 
pox, even  in  its  mildest  form,  was  apparently  as  contagious  as  the 
ordinary  disease,  the  actual  amount  of  smallpox  in  the  country, 
during  the  period  succeeding  the  introduction  of  inoculation,  was 
probably  much  higher  than  otherwise  would  have  been  the  case. 
At  the  present  day  inoculation  has  only  an  historic  interest,  seeing 
that  since  the  Vaccination  Act  of  1840  came  into  operation  the 
intentional  communication  of  smallpox  from  person  to  person  in 
this  manner  has  been  a  penal  offence. 

S,    MONCKTON    COPEMAN. 


328  MANUAL  OF  MEDICINE 

VACCINIA 

Syn.  Cow-pox 

Vaccination 

Vaccinia  is,  in  the  human  subject,  a  specific  communicable 
disorder,  arising,  except  in  very  rare  instances,  from  the  accidental 
or  intentional  inoculation  of  an  individual  with  vaccine  lymph. 
The  disease  is  characterised  by  the  appearance  of  a  local  eruption, 
passing  through  the  stages  of  papule,  vesicle,  and  pustule,  associated 
with  more  or  less  constitutional  disturbance. 

Similar  symptoms  are  produced  whether  the  lymph  employed 
for  inoculation  has  been  derived  from  the  vesicles  of  a  previous 
case  in  the  human  being,  or  from  the  eruptive  vesicles  of  a  disease 
of  bovine  animals  called  cow-pox.  Such  inoculation  process, 
whichever  way  induced,  is  known  as  vaccinatiofi.  This  name  was 
originally  devised  in  accordance  with  the  terminology  of  Jenner, 
who  wrote  of  the  disorder  under  the  title  of  Variolae  vaccinae.  In 
this  manner  he  gave  expression  to  his  belief  that  the  malady 
commonly  known  as  cow-pox  was  in  reality  nothing  more  nor  less 
than  smallpox  of  the  cow. 

Cow-pox  in  the  cow. — For  a  description  of  cow-pox  in  typical 
form,  as  it  was  known  to  Jenner  and  his  contemporaries,  it  is 
necessary  to  consult  the  writings  of  the  early  part  of  the  century, 
at  which  period  the  disorder  was  much  more  rife  than  at  the 
present  day.  According  to  observers  such  as  Bryce  and  Ceely, 
this  affection,  when  once  set  going  in  a  herd,  tends  to  spread  with 
considerable  rapidity,  the  "  matter "  of  the  vesicles  which  appear 
on  the  teats  and  udders  being  carried  by  the  hands  of  the  milkers 
from  one  cow  to  another.  If  the  material  happen  to  come  in 
contact  with  an  abrasion  of  the  skin  of  the  milker's  hand,  such 
person  is  apt  to  become  infected  with  the  disease.  When  the 
ailment  is  communicated  in  this  manner,  it  is  termed  casual  cow- 
pox,  to  distinguish  it  from  that  form  which  is  intentionally  pro- 
pagated by  vaccination,  under  which  circumstances  the  affection  is 
less  virulent  than  when  communicated  in  the  former  way. 

Inoculated  cow-pox  (vaccination)  in  man. — In  the  cow-pox 
induced  by  inoculation  the  appearances  which  present  themselves 
differ  in  some  respects  from  those  occurring  in  the  casual  disease, 


VACCINIA  329 

Thus  about  the  third  day  after  the  insertion  of  vaccine  lymph 
a  small  inflamed  spot  may  be  observed  at  the  point  where  the 
vaccination  was  performed.  Next  day  this  spot  appears  more 
florid,  and  on  passing  the  point  of  the  finger  over  it,  a  certain 
degree  of  hardness  and  swelling  is  perceptible.  By  the  fifth  day  a 
small  pale  vesicle  occupies  the  spot  where  the  inflammation  began. 
This  vesicle  has  a  milky-white  colour  without  any  inflammatory 
zone  around  it ;  it  is  depressed  in  the  centre,  its  edges  being 
distinctly  elevated.  For  the  next  two  days  the  vesicle  increases 
in  size,  assuming  a  circular  form  if  the  vaccination  was  performed 
by  a  puncture ;  if  done  by  an  incision,  an  oval  shape.  But  in 
both  cases,  the  margin  is  regular  and  well  defined.  About  the 
eighth  day  an  inflammatory  zone  (of  a  bright  red  colour,  termed 
the  areola)  begins  to  appear  around  the  base  of  the  vesicle.  This 
increases  for  two,  or  perhaps  three,  days  more,  by  which  time  it  may 
extend  for  about  a  couple  of  inches  from  the  vesicle.  The  vesicle 
still  retains  its  concave  appearance,  and  a  crust  of  a  brownish 
colour  will  have  commenced  to  form  in  the  centre.  About  the 
eleventh  day  the  vesicle  has  attained  its  greatest  magnitude,  and 
the  surrounding  inflammation  begins  to  abate.  The  fluid  in  the 
vesicle,  which  before  was  thin  and  transparent,  is  now  more  viscid 
and  somewhat  turbid.  After  this  period  the  whole  becomes  quickly 
converted  into  a  smooth,  shining,  drj-  crust  of  a  dark-brownish  or 
red  colour.  This  crust,  unless  forcibly  removed,  will  adhere  for  a 
week  or  more,  and  then  fall  off,  leaving  the  skin  beneath  appar- 
ently sound,  but  livid  for  a  time,  and  more  or  less  permanently 
scarred. 

Relationship  of  Variola  and  Vaccinia. — As  evidence  of  a 
definite  relationship  between  smallpox  and  cow-pox,  it  may  be 
mentioned  that  whereas,  prior  to  the  introduction  of  vaccination, 
epidemics  of  these  disorders  frequently  occurred  in  relation  to  one 
another,  the  so-called  "natural"  cow-pox  has  now  in  great 
measure  disappeared.  There  is,  moreover,  no  appreciable  diff'er- 
ence  in  the  anatomical  characters  or  in  the  progress  of  the 
eruption  in  the  two  aff'ections,  both  of  which  also  appear  to  be 
mutually  protective  against  each  other.  But  of  far  greater  import- 
ance in  this  connection  are  the  results  obtained  by  numerous 
observers,  who  in  various  parts  of  the  world,  and  almost  from  the 
time  of  Jenner  onwards,  have  set  themselves  the  task  of  attempting, 
by  experimental  methods,  to  solve  the  problem  of  the  true  relation- 
ship of  variola  to  vaccinia.  As  the  outcome  of  this  work  it  may 
now  be  definitely  stated  that   smallpox  lymph,  by  passmg  through 


330  MANUAL  OF   MEDICINE 

the  system  of  the  calf,  can  be  so  altered  in  character  as  to  become 
deprived  of  its  power  of  causing  a  generalised  eruption,  while 
inducing  at  the  site  of  inoculation  a  vesicle  indistinguishable  from 
a  typical  vaccine  vesicle ;  and  more  important  still,  that  when 
transferred  again  to  man,  it  has  by  such  treatment  completely  lost 
its  former  infectious  character.  Such  being  the  case,  it  may  fairly 
be  asserted  that  cow-pox — or  rather  that  artificially  inoculated  form 
of  the  disease  which  we  term  vaccinia — is  nothing  more  nor  less 
than  variola  modified  by  transmission  through  the  bovine  animal. 

Histology. — During  the  evolution  of  the  local  changes  which 
result  from  the  insertion  of  vaccine  lymph  beneath  the  surface  of 
the  skin,  it  is  possible  to  recognise  three  more  or  less  definite 
stages  of  papule,  vesicle,  and  pustule.  The  same  statement  holds 
good  with  reference  to  the  eruption  of  smallpox,  whether  this  be 
local,  i.e.  due  to  inoculation  of  the  virus,  or  general,  as  the  result 
of  infection. 

In  each  instance  the  appearance  of  the  first  ox  papular  stage  is 
brought  about  by  inflammatory  reaction,  causing  an  increase  of 
intercellular  fluid,  together  with  concomitant  increase  in  volume  and 
number  of  epithelial  ceUs,  of  the  rete  Malpighii  more  particularly. 
The  papule  gradually  becomes  enlarged  by  a  circumferential  ex- 
tension of  the  same  process,  and,  owing  to  further  changes  in  the 
cells  first  affected,  vacuoles  arise  in  the  central  portion  of  the 
papule,  by  the  extension  of  which  this  ultimately  becomes  a  vesicle. 
The  vesicle  is  a  multilocular  structure,  the  dissepiments,  by  means 
of  which  its  interior  is  divided  up,  being  formed  from  the  thinned 
and  extended  remains  of  the  original  epithelial  cells.  Owing  to  the 
fact  that  the  process  of  vacuolation  for  a  time  increases  more 
extensively  at  the  advancing  edge  of  the  vesicle,  the  central  portion 
remains  somewhat  less  elevated,  thus  giving  rise  to  the  appearance 
termed  umbilication.  At  a  quite  early  stage  of  the  process  an  out- 
flow of  leucocytes  takes  place  towards  the  point  of  injury.  These, 
by  the  increase  in  their  numbers,  eventually  transform  the  originally 
clear,  inflammatory  exudation  into  a  purulent  fluid.  The  vesicle  is 
said  now  to  have  become  converted  into  z. pustule.  By  the  thinning 
and  ultimate  rupture  of  its  trabeculae,  the  pustule  finally  becomes 
unilocular.  The  turbid  fluid  contained  in  it  now  gradually  dries  up, 
and,  together  with  the  necrosed  remains  of  epidermal  cells,  takes 
part  in  the  formation  of  the  crust.,  which,  under  the  microscope, 
appears  as  a  homogeneous  mass  very  deeply  coloured  by  the  ordinary 
bacteriological  stains.  Meanwhile  a  regeneration  goes  on  underneath 
the  crust,  the  new  epidermis  being  formed  from  an  ingrowth  from  the 


VACCINIA  331 

surrounding  stratum  lucidum.     The  extent  to  which  the  cutis  vera 
has  been  involved  determines  the  depth  of  the  resulting  scar. 

Bacteriology. — There  is  much  evidence  to  prove  'that  the 
results  following  on  the  process  ol  vaccination  are  due  to  a  specific 
contagium,  and,  moreover,  that  the  particular  micro  -  organism 
concerned  is  capable  of  existing,  during  one  period  of  its  life  cycle, 
in  a  resting  or  spore  form,  which  is  more  resistant  to  the  germicidal 
effects  of  glycerine  than  is  the  case  with  non-sporing  microbes.  Up 
to  the  present,  however,  no  satisfactory  method  has  been  devised  by 
which  the  micro-organism  of  vaccinia  can  be  unfailingly  cultivated 
on  artificial  media  while  still  retaining  its  specific  properties. 

History  of  vaccination. — Rather  more  than  a  century  ago,  in 
the  summer  of  the  year  1798,  there  was  published  a  pamphlet 
entitled  "  An  Inquiry  into  the  Causes  and  Effects  of  the  Variolse 
Vacciniae,  etc."  This  was  the  work  of  Edward  Jenner,  a  country 
medical  practitioner  living  at  Berkeley,  in  the  Vale  of  Gloucester, 
and  in  it  the  author  set  out  the  results  of  certain  investigations  on 
the  possibility  of  affording  protection  against  human  small-pox  by  the 
intentional  inoculation  of  a  disease  of  cattle  called  cow-pox. 

Many  years  before,  while  apprenticed  to  a  medical  man  at  Sod- 
bury,  near  Bristol,  Jenner's  attention  had  first  become  directed  to  a 
belief,  widely  prevalent  in  Gloucestershire  during  the  latter  half  of 
the  eighteenth  century,  that  those  persons  who  in  the  course  of 
their  employment  on  dairy  farms  happened  to  contract  cow-pox 
were  thereby  protected  from  a  subsequent  attack  of  smallpox.  In 
particular,  his  interest  was  aroused  by  a  casual  remark  made  by  a 
young  countrywoman,  who  happened  to  come  to  the  surgery  one 
day  for  advice,  and  who,  on  hearing  mention  made  of  smallpox, 
immediately  volunteered  the  statement  that  she  could  not  take  the 
disease  as  she  had  had  cow-pox. 

On  coming  up  to  London  in  1770  to  finish  his  medical 
education,  Jenner  became  a  pupil  of  John  Hunter,  with  whom  he 
frequently  discussed  the  question  of  the  possibility  of  obtaining 
protection  against  smallpox.  On  his  return  to  his  native  village  of 
Berkeley  in  1773  to  practice  as  a  medical  man  he  took  every 
opportunity  of  talking  over  and  investigating  the  matter,  but  it 
was  not  until  May  1796  that  he  commenced  actual  experiments. 
Jenner's  first  case  of  vaccination  was  that  of  a  boy,  eight  years  of 
age,  whom  he  inoculated  in  the  arm  with  cow-pox  matter  taken  from 
a  sore  on  the  hand  of  a  dairymaid,  who,  in  turn,  had  become  in- 
fected with  the  disease  from  milking  cows  suffering  from  cow-pox. 


332  MANUAL  OF  MEDICINE 

It  was  apparently  not  until  1798  that  he  made  his  first  attempt 
to  carry  on  a  strain  of  lymph  from  arm  to  arm.  In  the  spring  of 
this  year  he  inoculated  a  child  with  matter  taken  directly  from  the 
nipple  of  a  cow ;  and  from  the  resulting  vesicle  on  the  arm  of  this 
child  first  operated  on,  he  inoculated,  or,  as  it  may  now  be 
more  correctly  termed,  "vaccinated,"  another.  From  this  child 
several  others  were  vaccinated ;  from  one  of  these  a  fourth  remove 
was  carried  out  successfully,  and  finally  a  fifth.  Four  of  these 
children  were  subsequently  inoculated  with  small-pox — the  "  vario- 
lous test  " — without  result. 

Extent  of  the  protection  afforded  by  vaccination. — As 
the  result  of  prolonged  investigation  of  the  effect  of  vaccination  in 
reducing  the  prevalence  of,  and  mortality  from,  smallpox  the  follow- 
ing conclusions  were  arrived  at  by  the  majority  of  the  members  of 
the  Royal  Commission  on  Vaccination,  whose  final  report  was 
published  in  1896. 

1.  That  it  diminishes  the  liability  to  be  attacked  by  the  disease. 

2.  That  it  modifies  the  character  of  the  disease  and  renders  it  (a) 
less  fatal,  and  (d)  of  a  milder  or  less  severe  type. 

3.  That  the  protection  it  affords  against  attacks  of  the  disease  is 
greatest  during  the  years  immediately  succeeding  the  operation  of 
vaccination.  It  is  impossible  to  fix  with  precision  the  length  of  this 
period  of  highest  protection.  Though  not  in  all  cases  the  same,  if  a 
period  is  to  be  fixed,  it  might,  we  think,  fairly  be  said  to  cover  in 
general  a  period  of  nine  or  ten  years. 

4.  That  after  the  lapse  of  the  period  of  highest  protective  potency, 
the  efficacy  of  vaccination  to  protect  against  attack  rapidly  diminishes, 
but  that  it  is  still  considerable  in  the  next  quinquennium,  and  possibly 
never  altogether  ceases. 

5.  That  its  power  to  modify  the  character  of  the  disease  is  also 
greatest  in  the  period  in  which  its  power  to  protect  from  attack  is 
greatest,  but  that  its  power  thus  to  modify  the  disease  does  not 
diminish  as  rapidly  as  its  protective  influence  against  attacks,  and  its 
efficacy,  during  the  later  periods  of  life,  to  modify  the  disease  is  still 
very  considerable. 

6.  That  re-vaccination  restores  the  protection  which  lapse  of  time 
has  diminished,  but  the  evidence  shows  that  this  protection  again 
diminishes,  and  that,  to  ensure  the  highest  degree  of  protection  which 
vaccination  can  give,  the  operation  should  be  at  intervals  repeated. 

7.  That  the  beneficial  effects  of  vaccination  are  most  experienced 
by  those  in  whose  case  it  has  been  most  thorough.  We  think  it  may 
fairly  be  concluded  that  where  the  vaccine  matter  is  inserted  in  three  or 
four  places,  it  is  more  effectual  than  when  introduced  into  one  or  two 


VACCINIA  333 

places  only,  and  that  if  the  vaccination  marks  are  of  an  area  of  half  a 
square  inch,  they  indicate  a  better  state  of  protection  than  if  their  area 
be  at  all  considerably  below  this. 

Re  -  vaccination. — The  protection  afforded  by  a  primary 
vaccination  tends  gradually  to  diminish  and  eventually  to  disappear 
more  or  less  completely  with  the  lapse  of  time.  In  consequence,  it 
is  desirable  that  the  operation  should  be  repeated  at  the  age  of  from 
seven, to  ten  years,  and  thereafter,  if  it  be  possible,  at  intervals 
during  later  life.  The  Report  of  the  Royal  Commission  on 
Vaccination  thus  summarises  the  evidence  as  to  the  value  of  such 
additional  procedure. 

Where  re  -  vaccinated  persons  were  attacked  by,  or  died  from, 
smallpox,  the  re -vaccination  had  for  the  most  part  been  performed  a 
considerable  number  of  years  before  the  attack.  There  were  very  few 
cases  where  a  short  period  only  had  elapsed  between  the  re-vaccination 
and  the  attack  of  smallpox.  This  seems  to  show  that  it  is  of  import- 
ance in  the  case  of  any  persons  specially  exposed  to  the  risk  of  con- 
tagion that  they  should  be  re-vaccinated,  and  that  in  the  case  even  of 
those  who  have  been  twice  re-vaccinated  with  success,  if  a  long  interval 
since  the  last  operation  has  elapsed,  the  operation  should  be  repeated 
for  a  third,  and  even  for  a  fourth  time. 

It  not  unfrequently  happens  that  iii  the  case  of  a  re-vaccination 
the  process  runs  a  somewhat  different  course  to  that  witnessed  in  a 
typical  primary  vaccination.  Owing  probably  in  large  measure  to 
the  age  of  the  patient,  and  the  consequent  difficulty  in  keeping  the 
vaccinated  arm  completely  at  rest,  somewhat  extensive  inflammation 
of  the  skin  is  apt  to  ensue.  This  occasionally  may  be  further  com- 
plicated, it  may  be  with  lymphangitis,  swelling,  and  even  suppura- 
tion of  the  axillary  glands  and  general  malaise.  In  a  successful 
vaccination,  papules  make  their  appearance  about  the  third  to  the 
fifth  day  at  the  site  of  the  operation.  The  papules  may  or  may  not 
develop  further  into  vesicles  and  pustules.  Occasionally  a  second 
or  later  vaccination  appears  to  fail  altogether,  but  as  pointed  out 
by  the  Royal  Commission,  it  is  advisable,  as  in  the  case  of  a 
primary  vaccination,  to  make  further  attempts  before  concluding 
that  the  individual  is  really  insusceptible. 

Alleged  injurious  effects  of  vaccination. — In  a  certain 
small  proportion  of  cases  the  operation  of  vaccination  is  apt  to  be 
followed  after  a  longer  or  shorter  interval  by  various  complications, 
of  which  by  far  the  most  important  are  those  of  an  inflammatory 
nature,  which  "  constitute  the  danger  of   any  local  lesion  of  the 


334  MANUAL  OF   MEDICINE 

skin  "  (Acland).  Those  most  liable  to  be  met  with  include  erysipelas, 
septicaemia,  and  pysemia,  abscess,  and  ulceration,  simple  or  gan- 
grenous. Dr.  Acland  has  shown  that,  approximately,  60  per  cent 
of  all  cases  of  vaccinal  injury  in  this  country  are  probably  due  to 
some  form  of  inflammation,  erysipelas  being  the  most  important 
and  of  the  most  frequent  occurrence. 

There  is  unfortunately  some  reason  for  the  assertion  that 
syphilis  has,  on  occasion,  been  in-vaccinated,  although  the  number 
of  authenticated  cases  are  extremely  few.  Seeing,  however,  that 
the  use  of  calf  lymph  has  now  become  practically  universal,  the 
possibility  of  such  untoward  occurrence  in  the  future  may  be  dis- 
regarded, seeing  that  the  calf  is  not  capable  of  contracting  this 
disease. 

Tubercle  in  its  various  forms  and  leprosy  have  also  been  in- 
cluded in  the  list  of  possible  complications  of  vaccination,  though 
without  any  sufficient  proof.  The  employment  of  calf  lymph 
treated  with  glycerine  after  the  manner  first  advocated  by  the  writer, 
and  now  officially  adopted  by  the  Government,  will  obviate  any 
such  danger,  for  even  if  bacilli  of  tubercle  were  by  chance  present 
in  the  lymph  material  when  collected,  it  has  been  found  that  they 
are  quite  unable  to  survive  the  prolonged  action  of  a  fifty  per  cent 
solution  of  glycerine  in  water.  Leprosy  is  not  communicable  to 
the  calf. 

Certain  skin  diseases,  such  as  eczema  and  impetigo,  sometimes 
appear  during  the  course  of,  or  shortly  after,  vaccination ;  but  no 
direct  connection  has  been  proved  to  exist  between  the  operation 
and  the  occurrence  of  these  disorders. 

In  section  434  of  the  Final  Report  of  the  Royal  Commission  on 
Vaccination  the  extent  to  which  other  inoculable  diseases  are  liable 
to  complicate  vaccination  are  thus  summed  up  : — 

"  A  careful  examination  of  the  facts  which  have  been  brought 
under  our  notice  has  enabled  us  to  arrive  at  the  conclusion  that 
although  some  of  the  dangers  said  to  attend  vaccination  are  un- 
doubtedly real  and  not  inconsiderable  in  gross  amount,  yet  when 
considered  in  relation  to  the  extent  of  vaccination  work  done  they 
are  insignificant.  There  is  reason  further  to  believe  that  they  are 
diminishing  under  the  better  precautions  of  the  present  day,  and 
with  the  addition  of  the  future  precautions  which  experience 
suggests  will  do  so  still  more  in  the  future." 

The  nature  of  the  precautions  most  necessary  to  be  observed 
will  be  considered  in  a  separate  section. 


VACCINIA  335 

Practice  of  Vaccination 

CoUeetion  and  storagre  of  vaccine  lymph. — Hitherto  the  use 
of  arm-to-arm  human  lymph  has  been  insisted  on  in  th-is  country  in 
the  case  of  all  vaccinations  performed  at  public  stations,  for  the 
reason  that  until  recently  this  was  the  only  method  by  which  lymph 
stocks  could  be  perpetuated  and  the  greatest  possible  purity  of  the 
lymph  ensured.  In  view,  however,  of  the  recommendations  of  the 
Royal  Commission,  and  under  the  provisions  of  the  Vaccination  Act 
of  1898,  this  method  will,  as  regards  public  vaccinations,  be  discon- 
tinued in  the  future  in  favour  of  the  use  of  calf  lymph,  partly  with 
the  object  of  diminishing  the  very  remote  possibility  of  the  convey- 
ance of  syphilitic  infection  by  the  operation.  By  this  change  of 
method  also  the  necessity  for  opening  vaccination  vesicles,  and 
thereby  of  affording  opportunity  for  other  local  infections,  will  in 
large  measure  be  avoided. 

If  human  lymph  be  required  the  vesicles  should  be  opened  by 
a  number  of  minute  punctures,  which  must  be  made  on  its  surface 
and  not  around  its  base.  The  object  of  such  multiple  puncture  is 
to  open  the  various  cell-spaces  in  which  the  lymph  is  contained ; 
that  of  puncturing  on  the  surface,  rather  than  around  the  base,  is 
to  avoid  any  admixture  with  blood.  Lymph  soon  collects  in 
droplets  at  the  points  of  incision,  and  may  be  removed  on  a  lancet, 
or  if  required  for  use  at  a  distance,  may  be  taken  up  into  capillary 
tubes. 

To  fill  a  capillar}'  tube  it  should  be  held  in  a  more  or  less 
horizontal  position  and  one  end  applied  to  a  drop  of  lymph  exuding 
from  a  vesicle  which  has  been  punctured,  when  the  lymph  im- 
mediately enters  by  capillary  attraction.  No  more  should  be  allowed 
to  enter  than  is  sufificient  to  fill  the  tube  from  one-half  to  two- 
thirds  of  its  length.  The  tube  is  sealed  by  applying  the  empty  end 
to  the  flame  of  a  candle  or  spirit-lamp,  as  much  as  possible  of  the 
contained  air  having  been  previously  driven  out  by  momentarily 
plunging  into  the  flame  the  whole  of  that  portion  of  the  tube  in  which 
there  is  no  lymph.  By  this  means,  as  soon  as  the  extremity  is 
sealed,  the  column  of  lymph  is  driven  by  atmospheric  pressure 
towards  the  end  first  closed,  and  the  point  at  which  the  lymph  found 
entrance  can  then  be  sealed  in  the  flame  in  the  same  manner  as 
was  the  other. 

The  method,  formerly  employed,  of  storing  lymph  in  the 
dried  condition  on  ivory  points  is  not  to  be  recomme«ded. 

Glyeerinated   lymph. — The    almost   universal    occurrence    of 


336  MANUAL  OF  MEDICINE 

extraneous  microbes  in  vaccine  lymph,  and  the  chance  of  addition, 
during  or  after  vaccination,  of  pathogenetic  micro-organisms  by  agency 
of  careless  people,  whether  vaccinators  or  persons  having  charge  of 
infants,  have  been  advanced  as  reasons  for  avoiding  vaccination,  on 
the  ground  of  the  possible  harmfulness  of  micro-organisms  liable 
to  be  introduced  into  the  lymph  at  the  time  of  the  operation,  or 
subsequently  in  the  course  of  the  evolution  of  the  resulting  pock. 
This  argument,  however,  so  far  as  the  microbes  usually  intimately 
associated  with  lymph  are  concerned,  loses  whatever  weight  it  may 
have  had,  since  the  writer  has  shown  that  by  thoroughly  incorporat- 
ing the  lymph  or  vesicle  pulp  with  a  sterilised  fifty  per  cent  solution 
in  water  of  chemically  pure  glycerine,  and  afterwards  storing  the 
mixture  for  some  weeks  prior  to  use,  protected  from  light  and  air, 
all  the  ordinary  saprophytes  found  associated  with  lymph  are 
eventually  destroyed.  This  result  is  proved  by  the  fact  that  no 
growth  arises  in  any  of  the  ordinary  culture  media  inoculated  with 
such  glycerinated  lymph.  This  statement  applies  equally  to  the 
bacillus  of  tubercle  and  to  the  streptococcus  of  erysipelas,  should 
these  microbes  have  been  originally  present  in,  or  have  been  added 
experimentally  to,  the  lymph.  The  employment  of  glycerinated 
calf  lymph  is  now  ofificially  recognised  by  the  Government,  the 
lymph  being  issued,  free  of  charge,  to  public  vaccinators  in  any 
quantity  required. 

Insertion  of  vaeeine  lymph. — This  process  may  be  carried 
out  either  by  scarification,  by  puncture,  or  by  multiple  superficial 
incisions.  Doubtless  the  individual  operator  will  attain  the  greatest 
measure  of  success  by  employing  the  method  with  which  he  is 
most  familiar ;  but  there  can  be  little  doubt  that  the  method  of 
insertion  by  scarification  is  the  one  that  is  most  satisfactory,  more 
particularly  if  the  lymph  has  been  preserved  with  glycerine. 

The  mode  of  operation  is  briefly  as  follows  : — The  arm  should, 
if  possible,  be  first  washed  with  soap  and  warm  water,  and  after- 
wards carefully  dried  with  a  soft  towel,  gentle  friction  being  em- 
ployed so  as  to  cause  a  certain  amount  of  distension  of  the 
cutaneous  capillaries.  Drops  of  lymph,  corresponding  in  number 
to  that  of  the  vesicles  which  it  is  required  to  produce,  are  then  to 
be  placed  on  the  surface  of  the  arm,  and  the  skin  put  slightly  on 
the  stretch  with  the  fingers  of  the  left  hand.  Next,  the  skin  is 
scarified  by  a  system  of  "cross-hatching,"  through  the  drops  of 
lymph,  by  means  of  whatsoever  instrument  may  be  preferred,  care 
being  taken  not  to  place  the  insertions  too  closely  together,  lest  the 
vitality  of  the  tissues  between  them  be  injured. 


MUMPS  337 

An  ordinary  bleeding  lancet,  the  point  of  which  has  been 
slightly  blunted,  or  a  spear-pointed  surgical  needle,  are  both  very 
efificient  for  the  purpose  of  scarification.  Complicated  instruments 
should  be  avoided,  since,  as  a  rule,  it  is  difficult  to  keep  them 
thoroughly  clean.  The  special  advantage  of  a  needle  is  that  a 
new  one  can  be  employed  on  every  occasion.  If  a  lancet  or  like 
instrument  be  employed,  it  is  essential  that  it  should  be  boiled 
or  otherwise  sterilised  immediately  before  use. 

The  strictest  aseptic  precautions  should  also  be  observed  in  the 
immediate  and  subsequent  treatment  of  the  vaccinated  area.  With 
the  object  of  obtaining  this  result,  the  scarified  spots  should  be 
protected  either  by  a  dressing  of  boracic  lint,  or  by  being  covered 
over  with  a  layer  of  collodion  or  other  protective  tissue,  which,  if 
possible,  should  be  allowed  to  remain  undisturbed  for  at  least  a 
week.  On  inspection,  which,  by  the  regulations  of  the  Local 
Government  Board,  is  now  required  to  be  done  in  public  vaccina- 
tions between  the  sixth  and  fourteenth  day,  the  dressing  should  be 
renewed.  If,  by  any  chance,  the  vesicles  should  have  become 
ruptured,  the  use  of  a  pad  of  absorbent  wool  (or  wood-wool)  may 
be  advisable ;  otherwise  a  couple  of  layers  of  boracic  lint,  retained 
in  position  by  means  of  strapping,  will  suffice.  This  second  dress- 
ing should  be  left  on  the  arm  until  the  "crusts,"  to  which  the 
vesicles  will  have  given  rise,  have  separated  of  their  own  accord, 
and  the  regenerated  skin-area  beneath  is  soundly  healed. 

S.  MONCKTON    COPEMAN. 


MUMPS 
Syn.  Epidemic  Parotitis,  Infectious  Parotitis 

]\Iumps  is  an  acute  infectious  disease,  of  which  the  characteristic 
feature  is  inflammation  of  the  salivary  glands. 

Etiology. — It  has  been  known  to  occur  in  all  parts  of  the 
civilised  world,  chiefly  in  localised  outbreaks,  often  limited  to  the 
inhabitants  of  particular  institutions,  such  as  schools  or  barracks. 
Occasionally  its  prevalence  is  more  widely  spread. 

Of  recorded  epidemics,  the  largest  number  have  arisen  during 
the  winter  and  spring.  While  the  disease  is  met  with  at  all  periods 
vol.  I  2 


338  MANUAL   OF   MEDICINE 

of  life,  it  is  most  common  between  the  ages  of  five  and  fifteen. 
Both  sexes  are  equally  liable  to  be  attacked.  The  infection  is 
nearly  always  spread  directly  from  the  sick  to  the  healthy,  but  it 
may  be  conveyed  by  a  third  person  or  infected  articles. 

The  incubation  period  is  three  weeks ;  it  may  be  as  short  as 
fourteen,  and  as  long  as  twenty-five  days.  The  Medical  Officers  of 
Schools  Association  recommend  twenty-four  days'  quarantine,  dating 
from  exposure  to  infection,  if  disinfection  have  been  carried  out  at 
the  commencement. 

Symptoms. — In  some  cases  the  attack  is  ushered  in  by 
prodromal  symptoms — slight  sore  throat,  fever,  chilliness,  malaise, 
headache,  and  vomiting.  In  others  the  illness  begins  with  the 
signs  of  parotitis.  There  is  pain  behind  one  angle  of  the  jaw, 
which  is  quickly  followed  by  swelling  of  the  parotid  gland.  For 
two  or  three  days  the  swelfing  increases  till  it  extends  forwards  on 
the  cheek  and  downwards  to  the  neck ;  it  is  elastic  and  very 
painful.  The  skin  over  it  may  be  inflamed.  After  a  day  or  two 
the  swelling  subsides,  and  disappears  in  three  or  four  days. 

Often  the  affection  is  not  confined  to  one  parotid  gland.  The 
submaxillary  and  sublingual  salivary  glands  on  the  same  side 
become  involved,  and,  usually  after  an  interval  of  a  few  days,  the 
salivar)'  glands  of  the  opposite  side.  When,  as  occasionally  happens, 
both  sides  are  simultaneously  affected,  the  swelling  on  each  side 
of  and  below  the  jaw  gives  rise  to  deformity  so  great  as  to  render 
the  patient's  features  quite  unrecognisable. 

At  the  commencement  of  the  attack  the  temperature  may  rise 
to  102''  or  103-  F.,  and  for  a  day  or  two  remains  at  about  this 
height ;  then  it  gradually  falls  ta  the  normal,  to  rise  again  when 
the  second  gland  is  affected.  In  some  cases  there  is  no  pyrexia. 
The  pulse-rate  is  slightly  increased.  In  severe  cases  there  may  be 
delirium.  During  the  period  of  parotid  inflammation  the  patient 
experiences  great  pain  on  all  attempts  at  swallowing  or  speaking,  and 
sometimes  he  can  hardly  separate  his  teeth  without  discomfort. 
The  salivary  secretion  is  diminished  and  the  mouth  becomes  drj'. 
Occasionally  the  gums  are  swollen.  In  addition  to  the  salivary 
glands  the  cervical  lymph  glands  may  become  inflamed. 

The  disease  assumes  various  forms.  The  swelling  of  the 
parotid  glands  may  be  trivial.  In  rare  instances  the  submaxillary 
salivary  glands  alone  are  affected ;  or  the  salivar}'  glands  escape 
altogether,  and  the  cervical  lymph  glands  only  are  inflamed. 
Lastly,  orchitis  may  be  the  only  local  manifestation  of  mumps. 

It  is  very  rare  for  the  parotitis  to  suppurate  or  to  become  chronic. 


MUMPS  339 

Complications. — In  a  considerable  proportion  of  males,  usually 
adults  (2)3  per  cent,  Laveran),  oixhitis  follows  an  attack  of  mumps. 
This  event  generally  occurs  in  from  six  to  eight  days  after  the 
parotitis,  but  it  may  be  delayed  for  three  weeks.  In  rare  instances 
it  precedes  the  inflammation  of  the  salivary  glands.  The  body  of 
the  testis,  at  times  also  the  epididymis,  becomes  painful  and 
swollen,  attaining  a  considerable  size.  The  scrotum  may  be  red 
and  oedematous.  Even  in  slight  cases  pain  may  be  felt  extending 
up  the  cord  into  the  abdomen.  Occasionally  the  orchitis  is 
attended  by  severe  constitutional  symptoms — pyrexia  (102°  to 
105°  F.),  delirium,  vomiting  and  diarrhcea,  prostration,  and  in- 
frequent pulse.  The  orchitis  lasts  four  or  five  days,  and  is  as  a 
rule  one-sided.  It  is  followed  by  atrophy  of  the  testis  in  about  70 
per  cent  of  the  cases  (Laveran):  suppuration  is  rare.  In  the  adult 
female  also  the  sexual  organs  may  be  affected,  but  not  so  commonly 
as  in  the  male ;  so  that  there  is  ovarian  tenderness,  inflammation  of 
the  external  genitals,  and  mastitis. 

Other  complications  are  exceptional,  but  some  of  them  are 
serious.  Least  uncommon  are  ear -complicaf ions.  These  may 
either  accompany  or  follow  an  attack  of  mumps.  There  may  be 
deafness,  tinnitus  aurium,  vertigo  and  nausea  depending  upon 
inflammation  of  the  internal  ear.  The  deafness  may  become 
permanent,  but  is  rarely  double.  In  other  cases  there  is  otitis 
media.  With  respect  to  the  nervous  system.,  three  classes  of  cases 
have  been  recorded :  one  in  which  the  symptoms  point  to 
meningitis ;  a  second  in  which  they  seem  to  depend  on  the 
blocking  of  a  cerebral  vessel  (aphasia,  hemiplegia,  etc.) ;  and  a 
third  where  they  are  due  to  peripheral  neuritis. 

Amongst  very  rare  complications  may  be  mentioned — insanity, 
inflammation  of  the  lachrymal  gland  (with  orbital  pain  and  swollen 
eyelids),  jaundice,  oedema  glottidis,  bronchitis,  endocarditis,  arthritis, 
nephritis,  urethritis  and  prostatitis,  and  certain  skin  eruptions. 

Pathology  and  morbid  anatomy. — Mumps  is  most  probably 
caused  by  a  micro-organism,  which,  however,  has  not  yet  been 
identified,  that  reaches  the  glands  via  the  ducts,  and  induces  an 
inflammation  which  is  chiefly  interstitial. 

Relapses  and  second  attacks  are  uncommon.  Catin,  in 
an  epidemic  of  157  cases,  met  with  2  relapses  and  9  second 
attacks. 

The  patient  is  infectious  for  two  or  three  days  before  the 
parotid  swelling  arises,  and  the  aforesaid  authorities  advise  an 
isolation  of  the  patient  for  "not  less  than  three  weeks  from  the 


34<3  MANUAL  OF  MEDICINE 

commencement — provided  that  one  clear  week  has  elapsed  since 
the  subsidence  of  the  swelling." 

Diagnosis. — The  two  conditions  with  which  mumps  is  most 
often  confounded  are  diphtheria  and  enlargement  of  the  parotid 
gland  due  to  other  causes. 

It  is  the  extreme  enlargement  of  the  cervical  glands  present  in 
some  cases  of  diphtheria  which  occasions  the  error.  Inspection  of 
the  fauces  will  settle  the  case.  The  parotid  glands  are  unaffected 
in  diphtheria. 

Inflammatory  enlargement  of  the  parotids  sometimes  com- 
plicates other  diseases,  especially -enteric  fever  and  various  abdo- 
minal and  pelvic  disorders.     It  then  often  results  in  suppuration. 

Prognosis. — Mumps  is  very  rarely  fatal.  The  serious,  though 
unusual,  nervous  complications  mentioned  above  nearly  always 
occur  in  cases  where  the  testis  has  become  involved. 

Treatment. — To  the  painful  parotid  glands  hot  fomentations 
with  glycerine  and  belladonna,  or  laudanum,  should  be  applied. 
In  many  cases  of  orchitis  the  same  treatment  is  applicable,  but  in 
others  ice  affords  more  relief.  The  diet  should  be  such  as  the 
patient  can  take. 

It  is  most  important  to  bear  in  mind  that  orchitis  may  be 
induced  by  allowing  the  patient  to  get  up  and  resume  his  ordinary 
duties  too  early.  Hence  caution  should  be  exercised,  and  the 
male  patient  kept  in  bed  for  eight  or  nine  days,  and  in  his  room 
for  several  days  longer. 

E.  W.   GOODALL. 


WHOOPING-COUGH 
Syn.  Chin-Cough,  Pertussis 

An  acute  specific  disease — distinguished  by  general  catarrh  of 
the  respiratory  tract,  with  accompanying  nervous  phenomena,  of 
which  by  far  the  most  important  is  the  characteristic  laryngeal 
spasm.  It  is  very  infectious,  and  one  attack  usually  affords  com- 
plete protection  from  a  second  for  the  rest  of  life. 

Bacteriology.- — It  is  generally  recognised  that  the  contagium 
must  be  a  living  organism,  and  several  different  forms  have  been 
described,  but  the  real  one  has  not  yet  been  isolated  with  certainty. 


WHOOPING-COUGH  341 

Present  opinion  appears  to  be  in  favour  of  that  found  by  Koplick 
(and  possibly  previously  by  Afanasieff),  who  has  isolated  small 
bacilli  from  the  mucus  discharged  at  the  end  of  a  paroxysm,  which 
he  found  to  be  present  in  thirteen  out  of  sixteen  cases  examined. 
He  describes  them  as  very  minute  rods  with  rounded  ends,  which 
sometimes  look  like  diplococci  on  account  of  the  ends  being  the 
more  deeply  stained. 

Whatever  may  prove  ultimately  to  be  the  specific  organism, 
there  can  be  but  little  doubt  that  it  causes  an  inflammation  of  the 
mucous  membrane  of  the  larynx  and  trachea,  and  that  the  toxin 
which  it  manufactures  has  a  special  influence  on  the  centres  of  the 
pneumogastric  and  superior  laryngeal  nerves. 

Infection,  how  spread. — From  the  above  it  will  be  seen  that 
the  infection  is  contained  in  the  expectorated  mucus.  By  this 
means  the  disease  is  frequently  spread  through  the  medium  of 
clothes,  bedding,  curtains,  etc.,  as  is  the  case  with  scarlet  fever, 
though  how  long  the  virus  may  remain  active  in  such  circumstances 
is  very  doubtful.  From  outbreaks  recorded  as  having  taken  place 
on  board  ship,  the  fomites  would  appear  capable  of  conveying  in- 
fection for  several  weeks.  By  the  same  means  individuals,  them- 
selves unaffected,  may  convey  the  complaint. 

It  may  perhaps  also  be  spread  directly  by  the  breath,  but  if  so, 
the  infection  does  not  apparently  spread  very  widely — as  it  is  a 
matter  of  common  experience  to  those  connected  with  children's 
hospitals  that  the  tendency  for  the  disease  to  extend  to  the  sur- 
rounding beds  is  but  slight,  when  a  case  has  been  admitted  accident- 
ally into  the  wards. 

Duration  of  infectivity. — A  patient  is  infectious  from  the 
very  commencement  of  the  catarrhal  stage,  but  for  how  long  a  time 
after  has  not  been  settled ;  probably  there  is  but  little  danger  six 
weeks  after  the  onset  of  symptoms,  even  though  the  paroxysmal 
cough  may  not  have  entirely  disappeared. 

In  the  4th  edition  of  A  Code  of  Rules  for  the  Prevention  of  In- 
fectious and  Contagious  Diseases,  issued  by  the  Medical  Officers  of 
Schools  Association,  the  answer  to  the  question  when  a  patient 
can  be  considered  as  free  from  infection  is  laid  down  as  "in  not  less 
than  five  weeks  from  the  commencement  of  the  whooping,  and  pro- 
vided that  the  characteristic  spasmodic  cough  and  the  whooping 
have  ceased  for  at  least  two  weeks,"  and  "  provided  patient  and 
clothes  have  been  disinfected." 

In  the  same  work,  twenty-one  days  from  the  date  of  exposure  to 
infection  is  given  as  the  proper  period  of  quarantine,  with  a  similar 


342  MANUAL  OF   MEDICINE 

proviso  that  disinfection  has  been  carried  out  at  the  commence- 
ment. 

Predisposing  causes. — The  disease,  as  already  stated,  is  ex- 
tremely infectious,  and  persons  of  all  ages  are  liable  to  be  attacked. 
The  great  majority  of  cases  occur  between  the  ages  of  one  and 
ten  years,  a  period  which  includes  the  time  at  which  most  children 
are  first  exposed  to  the  infection.  A  good  many  infants  of  under 
one  year  of  age  suffer,  and  with  them  it  is  nearly  always  a  serious 
and  often  a  fatal  disease.  With  adults  and  old  people  it  is  trouble- 
some but  hardly  ever  dangerous.  Statistics  show  that  girls  are 
slightly  more  susceptible  than  boys. 

An  attack  of  measles  appears  to  render  an  individual  unduly 
susceptible  to  invasion  by  the  virus  of  whooping-cough,  at  any  rate 
in  this  country  there  is  a  very  general  belief  that  there  is  some  close 
connection  in  this  respect  between  the  two  diseases.  No  other 
factor  seems  to  have  a  direct  bearing  on  predisposition.  Ill- 
nourished  children  and  those  that  are  rickety  or  unusually  nervous 
make  bad  subjects,  as  they  appear  to  be  far  less  able  to  resist  the 
pulmonary  and  other  complications  which  so  frequently  arise. 

Epidemics  appear  to  be  most  prevalent  during  the  late  autumn, 
winter,  and  early  spring  months ;  certainly  those  that  suffer  during 
this  period  of  the  year  are  far  less  likely  to  get  well  quickly  than 
those  who  have  it  during  the  warmer  months. 

The  period  of  incubation  is  difficult  to  ascertain  with  precision, 
and  cannot  be  quite  definitely  stated.  Thirteen  days  was  found  by 
Dr.  Murchison  in  one  case  to  be  the  exact  period  ( Trans.  Clin.  Soc. 
vol.  xi.  p.  243  et  seq),  and  some  other  observers  have  confirmed 
this.  It  probably  varies,  however,  in  different  individuals  from  four 
or  five  to  eighteen  days,  or  even  longer. 

Clinical  history. — Incubation  over,  the  active  phase  of  the 
disease  sets  in,  and  this  may  be  conveniently  divided  into  three 
stages  :  (i)  prodromal;  (2)  paroxysmal;  and  (3)  that  of  defervescence. 
Between  the  first  and  second  the  distinction  is  fairly  sharp,  but  the 
latter  usually  passes  so  gradually  into  the  last  as  to  make  it  im- 
possible to  say  exactly  where  the  one  ends  and  the  other  begins. 

Prodromal  stage. — The  first  or  prodromal  stage  generally  lasts 
about  a  week  or  ten  days.  It  is  often  acute,  having  all  the 
characters  of  a  severe  cold,  with  considerable  disturbance  of  the 
respiratory  tract,  accompanied  by  more  or  less  catarrh  of  its  mucous 
membrane.  The  temperature  is  generally  moderately  raised.  The 
amount  of  malaise  varies  greatly,  but  is  often  only  slight. 

The  impossibility  of  recognising  the  disease  during  this  early 


WHOOPING-COUGH  343 

stage  is  unfortunate,  as,  owing  to  its  extreme  infectiousness,  it  is  the 
time  at  which  much  mischief  in  spreading  the  disease  occurs.  If  a 
cold  seems  to  be  particularly  severe  as  compared  to  the  physical 
signs  present,  if  the  bouts  of  coughing  have  any  tendency  to  be 
more  frequent  by  night  than  by  day,  and  particularly  if  they  are 
accompanied  by  any  tendency  to  vomiting,  suspicion  as  to  the  case 
being  one  of  whooping-cough  should  always  be  roused,  and  if  any 
cases  of  the  disease  are  known  to  be  in  the  neighbourhood,  these 
suspicions  would  be  very  much  strengthened.  Towards  the  end  of 
this  stage,  the  attacks  of  coughing  will  gradually  get  more  severe, 
increasing  in  frequency,  especially  at  night,  and  tending  to  become 
distinctly  paroxysmal.  With  each  attack  the  congestion  of  the  face 
becomes  more  marked,  and  some  of  them  are  very  likely  to  be  accom- 
panied by,  or  finish  up  with  an  attack  of  vomiting.  At  length  all 
doubt  is  set  at  rest  by  one  of  the  paroxysms  ending  with  the  peculiar 
whoop,  when  the  second  or  paroxysmal  stage  has  become  established. 

Paroxysmal  stage. — This  is  the  typical  period  of  the  disease, 
during  which  it  is  at  its  height,  and  when  all  its  characteristics  are 
most  marked.  The  chief  of  these  are  the  paroxysmal  bouts  of 
coughing.  These  may  either  come  on  apparently  spontaneously  or 
be  obviously  started  by  some  external  stimulus,  such  as  a  draught  of 
cold  air  or  the  banging  of  a  door,  etc.  The  total  number  of  attacks 
during  the  twenty-four  hours  varies  within  wide  limits,  from  some  i  o 
or  12  in  slight  cases  up  to  50  or  60  in  severe  ones.  A  certain 
grouping  of  the  paroxysms  is  occasionally  observable,  one  attack 
being  rapidly  followed  by  a  second  or  even  a  third,  which,  however, 
are  always  less  severe  than  the  first  of  the  series.  The  intervals 
between  one  paroxysm  or  group  of  paroxysms  and  the  next  are  of 
more  or  less  equal  length,  provided  that  no  external  stimulus,  as 
mentioned  above,  should  excite  an  attack.  There  is,  however,  a 
distinct  tendency  for  the  paroxysms  to  be  more  frequent  and  severe 
at  night.  It  is  a  good  plan  to  keep  a  record  of  the  paroxysms,  as  a 
comparison  of  the  numbers  from  day  to  day  gives  a  fair  indication 
of  the  general  progress  of  the  case. 

When  an  attack  is  about  to  occur  the  patient  frequently  appears 
to  have  some  sort  of  warning,  and  probably  desists  from  whatever 
he  may  be  doing — such  as  playing  with  his  toys.  He  assumes  an 
anxious  look  and  may  very  likely  get  up  and  run  to  his  mother  or 
nurse,  amongst  the  folds  of  whose  dress  he  tries  to  bury  his  head. 
Then  the  spasm  comes  on.  As  a  rule  the  child  holds  his  head  forward 
with  the  face  looking  a  little  downwards,  with  the  mouth  partly  open 
and  the  tongue  pushed  forward  as  far  as  the  lips,  or  even  protruding 


344  MANUAL  OF   MEDICINE 

slightly  beyond  them.  The  spasm  consists  essentially  in  a  series  of 
expiratory  explosions — during  which  all  the  usual  appearances  of 
asphyxia  arise,  and  may  persist  until  the  onlooker  begins  to  wonder 
if  the  child  will  not  actually  die  from  suffocation,  as  he  assumes  a 
horrible  look  with  puffy  eyelids,  deeply  congested  face,  with  engorged 
veins  and  turgid  neck.  Then  there  is  sudden  relaxation  with  a  long 
inspiration,  during  which  the  air  rushing  in  through  the  larynx 
produces  the  whistling  whoop  or  crowing  sound,  which  may  be 
repeated  after  a  second  or  even  a  third  spasm,  and  then,  as  the 
attack  passes  off,  the  child  very  frequently  vomits  the  contents  of 
the  stomach.  At  the  same  time,  or  may  be  later,  a  pellet  or  even 
a  tolerably  large  quantity  of  translucent,  perhaps  stringy,  mucus  is 
expectorated. 

A  period  of  quiescence  now  sets  in,  which  varies  very  markedly 
in  duration  and  intensity  in  different  individuals  and  in  accordance 
with  the  severity  of  the  spasm ;  it  may  hardly  exist.  The  child 
almost  directly  resumes  his  previous  occupation,  such  as  playing  with 
his  toys,  apparently  quite  free  from  trouble  and  as  though  he  had 
forgotten  all  about  the  attack.  The  play  with  which  he  occupies 
himself  is  nearly  always,  however,  of  some  quiet  kind.  From  this 
there  are  all  stages,  up  to  an  extreme  degree  of  collapse,  the  child 
falling  back  perfectly  exhausted  and  apathetic,  from  which  he  may 
only  be  aroused  by  the  onset  of  the  next  paroxysm. 

Physical  signs  in  the  chest. — Where  there  are  no  severe  com- 
plications the  signs  are  very  few.  During  the  inspiratory  stage  of 
the  spasm  nothing  can  be  heard  in  the  chest  with  the  stethoscope 
but  the  whoop,  which  is  conducted  to  the  surface.  In  the  intervals 
a  few  rhonchi  may  be  audible.  Often,  however,  there  is  singularly 
little  to  be  heard,  and  this  is  a  point  of  some  value  in  diagnosis— 
where  a  history  is  given  of  attacks  of  coughing  which  in  severity 
are  out  of  all  proportion  to  the  physical  signs  discoverable  in  the 
lungs  and  are  especially  frequent  and  troublesome  at  night. 

In  infants  occasionally  a  slight  emphysema  occurs,  which,  with 
their  soft-walled  chests,  may  lift  the  sternum  slightly  forwards.  This 
emphysema  is  probably  due  to  over-inflation  of  the  individual  alveoli 
merely,  without  any  breaking  down  of  their  walls,  though  this  may 
occur,  and  indeed  spread  beyond  the  lungs  and  air  passages  into  a 
more  or  less  extensive  "  surgical  emphysema." 

The  expression  during  an  attack,  as  mentioned  above,  is  very 
characteristic.  The  tongue,  from  its  being  pushed  forward  against 
the  lower  teeth,  is  likely  to  become  abraded,  and  when  only  the  two 
lower  central  incisors  are  present  two  small  ulcers  are  frequently 


WHOOPING-COUGH  345 

formed  on  its  under  surface,  one  on  each  side  of  the  frgenum,  which 
are  exceedingly  suggestive,  though  not  absolutely  pathognomonic  of 
the  disease.  The  tongue,  as  indeed  the  whole  face,  is  often  a  little 
swollen. 

The  entire  alimentary  canal  is  probably  congested  or  even 
inflamed,  as  not.  only  does  the  vomit  frequently  contain  a  good  deal 
of  mucus,  but  there  is  often  also  a  decided  looseness  of  the  bowels, 
which,  however,  only  very  rarely  becomes  at  all  serious. 

Complications. — The  most  important  complications,  owing  to 
their  frequency,  are  those  connected  with  the  lungs,  and  it  is  note- 
worthy that  the  whoop  is  liable  to  disappear  in  those  which  are 
accompanied  by  fever. 

Bronchitis. — There  is  almost  always  some  catarrhal  inflammation 
of  the  bronchial  tubes  present,  which  may,  however,  be  so  slight  that 
the  only  evidence  of  it  is  that  an  occasional  rhonehus  may  be 
heard.  Generally,  however,  the  bronchitis  is  well  marked,  the  larger 
and  medium  tubes  especially  being  affected — giving  rise  to  well- 
marked  sonoro-sibilant  rhonchi ;  but  occasionally  it  extends  into  the 
smallest  tubes,  when  the  grave  signs  and  symptoms  of  acute  capillary 
bronchitis  are  present,  and  this  condition  is  nearly  always  accom- 
panied with  a  greater  or  less  extent  of  pulmonary  collapse. 

Broncho-pneuvionia. — In  addition  to  the  bronchitis,  patchy  pneu- 
monic consolidation  not  unfrequently  occurs,  and  is  of  very  great 
importance,  as  the  high  mortality  of  whooping-cough  is  very  largely 
due  to  this  complication  ;  hence  its  onset  is  always  serious,  and  if 
the  child  be  constitutionally  weak,  and  particularly  if  he  be  the 
subject  of  rickets,  the  outlook  becomes  extremely  grave.  The 
condition  is  recognised  by  the  physical  signs  in  the  chest  and  re- 
mittent pyrexia  and  dyspnoea. 

Lobar  pneumo7iia  with  occasional  pleurisy. — Lobar  pneumonia 
occasionally  occurs,  but  is  very  much  less  frequent  than  the  other 
form.  Pleurisy  with  or  without  effusion  may  accompany  either  form 
of  pneumonia. 

Acute  bronchiectasis. — A  rare  condition  recently  described  by 
Dr.  Sharkey  (St.  Thomas's  Hospital  Reports,  vol.  xxii.)  appears 
occasionally  to  start  during  an  attack  of  whooping-cough.  The 
physical  signs  and  symptoms  are  so  obscure  that  it  has  not  yet  been 
recognised  during  life  as  distinct  from  bronchitis. 

Hceinoi-rhages. — Subconjunctival  ecchymoses  or  slight  attacks  of 
epistaxis  are  common,  but  not  in  any  way  serious ;  on  the  other 
hand,  should  the  haemorrhage  occur  from  a  vessel  in  connection 
with  the  brain  or  spinal  cord  an  extensive  paralysis  may  be  the  result. 


346  MANUAL   OF    MEDICINE 

Aade  nephritis  has  very  rarely  been  met  with  after  pertussis. 

Nervous  disturbafices. — Various  other  nervous  phenomena  may 
occur  which  cannot  be  attributed  to  hsemorrhage. 

There  can  be  no  doubt  that  the  nervous  system  is  profoundly 
disturbed.  The  very  paroxysm  of  whooping-cough  is  like  a  nerve 
storm  which  originates  in  the  pneumogastric  centres  of  the  medulla 
oblongata. 

Epilepsy  and  insanity  have  been  reported  as  having  become 
apparent  for  the  first  time  during  an  attack  of  whooping-cough  or 
shortly  afterwards,  and  localised  paralyses,  which  from  their  mode  of 
onset  have  been  attributed  to  neuritis,  have  also  been  seen.  Con- 
vulsions frequently  occur,  particularly  at  the  termination  of  a  severe 
paroxysm.  They  should  always  be  carefully  noted,  as,  although 
they  may  be  merely  the  result  of  venous  congestion  produced  by 
the  paroxysm,  and  have  no  significance  beyond  bemg  an  evidence 
of  the  unsettled  condition  of  the  nervous  tissue,  they  may  be  the 
prelude  of  some  grave  complication.  They  are  also  serious  on 
their  own  account,  as  there  is  some  evidence  to  show  that  death 
may  be  directly  produced  by  them. 

Defervescence. — The  acuteness  of  the  paroxysmal  period  gradu- 
ally subsides.  After  about  a  month  to  six  -weeks  from  the  onset  of 
the  disease  the  parox}'sms  become  less  frequent,  and  the  whoop  less 
definite  and  characteristic,  so  that  in  six  weeks  from  when  it  was 
first  heard  it  has  generally  subsided.  If  it  should  continue  longer 
this  is  generally  due  either  to  habit  or  to  the  presence  of  adenoids 
in  the  pharynx.  Occasionally,  a  week  or  two  after  the  paroxysmal 
stage  has  begun  to  subside,  there  is  a  recrudescence,  apparently  due 
to  the  "  catching  "  of  a  fresh  cold,  but  unless  this  passes  on  to  an 
attack  of  something  more  serious,  it  soon  subsides  and  merges  into 
the  next  stage,  that  of  convalescence. 

Convalescence. — This  period  may  be  rapid,  particularly  in  the 
warm  months  of  the  year,  but  it  may  be  very  protracted,  the  child 
remaining  listless  and  below  par  for  a  long  time.  It  is  during  this 
stage  that  any  latent  weakness  or  tendency  is  so  liable  to  manifest 
itself.  The  lungs  are  often  long  in  clearing  up,  traces  of  bronchitis 
remain,  and  this  condition  may  become  chronic.  However, 
fortunately,  convalescence,  though  so  often  tedious,  is  usually 
complete,  and  the  patient  recovers  perfectly. 

Sequelse. — Sequelse,  in  contradistinction  to  complications,  are 
not  numerous.  Any  latent  weakness,  such  as  quiescent  tubercle,  is 
very  likely  to  break  out  into  renewed  activity,  and  the  occasional 
appearance  of  epilepsy,  etc.,  has  already  been  referred  to. 


WHOOPING-COUGH  347 

Morbid  anatomy. — After  death,  the  changes  that  are  found  in 
the  tissues  are  those  of  the  various  compHcations  which  have  been 
already  alluded  to ;  there  are  none  which  can  be  considered  as  dis- 
tinctive of  the  disease. 

Diagnosis. — In  the  early  stages  it  may  be,  and  often  is,  impos- 
sible to  make  a  diagnosis.  There  is  usually  but  little  difficulty  when 
once  the  whoop  has  been  heard. 

Infants  by  no  means  always  develop  the  whoop ;  but  in  their 
case  a  clue  is  often  obtained  from  the  fact  that  other  members  of  the 
family  have  whooping-cough.  In  the  absence  of  any  such  help  the 
diagnosis  is  frequently  extremely  difficult.  The  paroxysmal  character 
of  the  cough,  accompanied  by  marked  congestion  of  the  face,  vomit- 
ing, and  possibly  some  nervous  phenomena,  are  then  the  signs  and 
symptoms  on  which  the  diagnosis  is  made ;  but  the  whole  course  of 
the  disease  may  be  run  through  without  its  true  nature  ever  being 
suspected.  The  crow  of  laryngismus  stridulus  somewhat  resembles 
the  whoop  of  this  disease,  but  the  other  characters  of  that  condition 
are  so  well  marked  that  there  is  but  little  practical  difficulty  in 
distinguishing  between  them.  Some  children  have  occasionally  a 
whistling  inspiration  when  they  cough ;  this  may  cause  some  trouble 
at  first,  but  a  consideration  of  the  other  characters  of  the  cough  is 
generally  sufficient  to  prevent  a  mistake. 

There  is  a  real  difficulty  in  separating  whooping-cough  from 
certain  cases  with  enlarged  bronchial  glands  in  the  posterior  medi- 
astinum. In  these  cases  the  cough  is  paroxysmal,  and  accompanied 
by  a  regular  whoop.  It  is  only  after  some  time  has  elapsed,  and 
repeated  examinations  made,  with  a  most  careful  weighing  of  all  the 
evidence,  that  a  correct  conclusion  can  be  arrived  at. 

Prognosis. — The  prognosis  of  the  uncomplicated  cases  is  favour- 
able ;  nevertheless  the  mortality  is  high,  and  is  affected  by  one  or 
more  of  the  following  factors  :  In  early  infancy  the  disease  is  always 
attended  with  anxiety,  owing  to  the  liability  of  extensive  pulmonary 
collapse  supervening,  and  this  danger  will  persist  beyond  the  first 
year  of  life  if  the  subject  be  rickety,  the  softened  ribs,  the  malnutri- 
tion and  disturbance  of  the  nervous  system,  all  contributing  to 
undermine  the  patient's  chances  of  recovery.  Lung  affections,  at  all 
ages,  are  the  most  serious  consideration,  and  in  the  large  majority  of 
cases  the  prognosis  hinges  on  their  severity.  The  condition  of  the 
nervous  system  is  also  an  important  factor.  Very  emotional  children, 
and  those  who  come  of  a  highly  neurotic  stock,  make  bad  subjects, 
and  frequently  have  the  disease  in  an  aggravated  form.  Should  a 
haemorrhage   occur,   the  prognosis   is  determined  by   its   seat   and 


348  MANUAL  OF   MEDICINE 

extent ;  but  the  general  testimony  of  observers  is  one  rather  of 
astonishment  that  nerve  lesions,  which  at  first  seemed  so  serious,  are 
so  frequently  completely  recovered  from.  Adenoids  are  justly  credited 
with  prolonging  the  convalescence. 

Treatment. — Ordinary  hygienic  rules  must  be  carefully  followed. 
As  soon  as  the  condition  is  suspected  or  recognised,  the  child  should 
be  isolated  from  any  that  have  not  yet  had  it.  He  should  be  kept 
in  two  rooms — one  for  the  day  and  the  other  for  the  night ;  and  the 
atmosphere  of  the  one  in  which  he  is  should  be  maintained  at  an 
equable  temperature  of  65°  Fahr.  The  importance  of  the  two  rooms 
is,  that  when  the  one  is  occupied  the  other  may  be  thoroughly  well 
ventilated  by  having  the  windows  left  wide  open,  care,  of  course, 
being  taken  that  it  is  of  the  proper  temperature  before  he  returns  to 
it.  If  at  the  onset  any  fever  be  present,  it  may  be  advisable  to  keep 
him  entirely  confined  to  bed  until  this  subsides ;  but  then,  unless 
complications  have  set  in,  it  is  better  for  him  to  be  up.  It  is  of 
advantage  to  charge  the  air  of  the  room  with  some  vapour — by  vola- 
tilising Friar's  balsam,  carbolic  acid,  creasote,  naphthalene,  turpentine, 
or  eucalyptus  oil.  The  suggestion  for  this  came  from  the  old- 
fashioned  remedy  of  stirring  Stockholm  tar  with  a  hot  poker,  or  of 
taking  children  into  the  purifying  chambers  at  gasworks.  If  the 
weather  be  favourable,  the  child  may  go  out ;  but  exposure  to  any 
inclemency  of  the  weather  must  be  carefully  guarded  against,  and  if 
any  acute  complication  be  present  he  must  be  kept  within  doors, 
where  he  should  be  allowed  to  amuse  himself  quietly,  but  be  kept 
as  far  as  possible  from  any  form  of  excitement  or  emotional  dis- 
turbance. 

Feeding  and  diet. — So  long  as  the  vomiting  is  not  troublesome, 
no  precautions  need  be  taken  beyond  ensuring  that  the  food  be  light 
and  wholesome.  Meals  should  be  frequent  and  small  in  quantity, 
and  consist  of  beef-tea,  gravy,  milk,  eggs,  fish,  bread,  sponge-cakes, 
custards,  stewed  and  fresh  fruit.  If  the  vomiting  becomes  at  all 
serious,  it  is  a  good  plan  to  give  some  food  as  soon  after  the  paroxysm 
as  possible. 

The  list  of  drugs  that  have  been  brought  forward  at  one  time  or 
another,  as  specifics  for  this  disease,  is  a  long  one,  yet  none  have 
been  proved  to  be  worthy  of  the  title ;  still,  some  are  found  occa- 
sionally to  be  of  decided  use. 

In  uncomplicated  cases  belladonna,  in  combination  with  bromide 
of  potassium,  has  been  a  general  favourite  ;  a  very  suitable  prescrip- 
tion for  a  child  about  two  or  three  years  of  age  being — 


m 

i. 

gr- 

iii 

in 

X 

ad 

5  ii 

WHOOPING-COUGH  349 

Extract!  belladonnae  liquid! 

Potassii  bromidi     .... 

Glycerini        ..... 

Aquam  destillatam 
Misce.  Fiat  haustus. 
To  be  taken  every  four  hours. 

The  belladonna  should  be  pushed  until  slight  flushing  occurs,  but 
not  so  far  as  to  cause  dryness  of  the  mouth  or  stomach  irritation. 
Trousseau  recommended  that  the  belladonna,  or  preferably  atropine, 
should  be  gradually  increased  over  a  period  of  three  days,  until  the 
pupils  began  to  dilate,  and  then  in  just  sufficient  quantity  to  maintain 
this  condition  for  about  a  week. 

Antipyrin  or  phenacetin  have  given  good  results  in  one,  two,  or 
three  grain  doses,  every  four  or  six  hours. 

Carbolic  acid  is  useful,  and  well  borne  even  by  infants,  the 
glycerinum  acidi  carbolici  being  a  good  preparation  to  use  in  doses  of 
four  or  five  minims. 

If  there  be  much  insomnia,  or  any  tendency  to  convulsions,  butyl 
chloral  hydrate,  given  in  grain  doses  every  hour,  is  often  most  effi- 
cient. In  very  severe  cases,  where  the  number  of  spasms  exceed 
twenty  in  the  day.  Dr.  Henoch  has  pushed  morphine  in  doses  varying 
from  ^^2"  to  \  grain,  with  the  best  results.  Bromoform,  in  minim 
doses,  has  considerable  effect  in  controlling  the  vomiting,  and  appears 
frequently  to  distinctly  reduce  the  severity  of  the  paroxysm. 

Expectorants  are  useful,  especially  if  there  is  any  considerable 
degree  of  bronchitis  present,  ipecacuanha  or  squills  being  generally 
used.  They  can,  of  course,  be  combined  with  almost  any  of  the 
foregoing  drugs. 

Local  treatment. — Local  treatment,  by  direct  application  either  by 
brush  or  spray,  has  been  very  strongly  advocated.  The  latter  is 
probably  preferable,  as  the  use  of  a  brush  is  liable  to  terrify  the  child, 
and  emotional  disturbances  should  be  avoided.  However,  excellent 
results  have  been  recorded  from  the  frequent  painting  of  the  larynx 
and  adjacent  parts  with  a  two  per  cent  solution  of  resorcin,  and  quite 
recently  very  weak  solutions  of  formalin  have  been  recommended  to 
be  tried  in  a  similar  way. 

The  external  application  of  turpentine,  or  ammoniated  camphor 
liniment,  or  other  stimulant  to  the  chest  wall  has  many  advocates. 

F.  G.  Penrose. 


350  MANUAL  OF  MEDICINE 


DENGUE 

Syn.   Dandy  Fever,  Break  Bone  Fever 

A  specific  infectious  malady  occurring  in  rapidly  spreading 
epidemics,  and  attended  by  the  sudden  onset  of  severe  pains  in 
the  limbs  and  joints,  a  high  temperature,  and  a  marked  eruption 
of  a  rubeolar  character. 

Geographical  distribution. — So  far  as  is  known,  dengue  may 
occur  anywhere  in  tropical  or  sub-tropical  countries.  In  Europe  it 
has  appeared  in  the  Turkish,  Grecian,  and  Russian  (Black  Sea) 
ports ;  in  America  it  affects  chiefly  the  West  Indies,  but  has  been 
known  to  extend  northwards  as  far  as  Philadelphia,  and  southward 
to  the  Argentine.  All  countries  bordering  on  the  Indian  Ocean 
have  been  frequently  visited  by  dengue,  and  the  Far  East  and 
Australia  have  suffered  from  epidemics  of  the  disease.  It  especially 
tends  to  spread  along  the  sea  coasts,  and  inland  along  the  banks  of 
rivers,  thus  resembling  yellow  fever,  and  rarely  invades  elevated 
districts. 

Dengue  attacks  all  and  sundry,  from  young  children  to  persons 
of  extreme  age.  When  it  breaks  out  in  a  village,  in  a  school,  or 
barracks,  the  majority  of  persons  of  the  community  are  quickly 
seized.  The  disease  tends  to  follow  the  lines  of  human  intercourse; 
a  ship  bearing  infected  passengers  frequently  setting  up  fresh  foci  of 
infection  at  each  port  of  call.  Hot  weather  favours  its  development, 
and  as  a  general  rule  cold  weather  stays  its  progress.  Like  other 
maladies  of  this  class  it  exhibits  recurrent  periods  of  greater  intensity 
and  wider  distribution. 

Nothing  is  known  concerning  the  bacteriology  of  the  disease. 

Incubation.  —  One  to  five  days  is  the  period  of  incubation 
usually  assigned  to  dengue.  During  incubation  symptoms  seldom 
show  themselves,  but  in  some  instances  muscular  aches  and  joint 
pains  precede  the  onset  of  fever. 

Symptoms. — Dengue  usually  attacks  quite  suddenly ;  in  the 
majority  of  instances  it  is  ushered  in  by  headache,  pains  in  the 
back,  limbs  and  joints,  fever,  chilliness,  or  even  a  rigor  and  an 
intense  feeling  of  weakness.  Or  the  initial  feeling  of  prostration 
may  continue  for  a  few  days,  accompanied  by  giddiness,  nausea, 
alternate    sensations    of   chilliness    and    heating,    flushings,    and    a 


DENGUE  351 

gradual  development  of  rheumatic  pains  in  the  limbs,  body,  and 
joints.  The  joint  pain  is  peculiar ;  the  first  symptom  may  be  a 
sudden  seizure  of  pain  in  one  finger,  or  the  pain  may  rapidly  extend 
to  almost  every  joint  in  the  body ;  or  it  may  fly  from  one  joint 
to  another,  disappearing  as  suddenly  as  it  came. 

The  first  eruption. — On  the  third  day  the  temperature  rises,  it 
may  be,  to  102°  F.,  or  even  to  106^  F. ;  the  pulse  becomes  rapid  ; 
the  skin  hot  and  dry ;  the  face  looks  swollen,  and  the  whole  body 
is  covered  by  a  rash  resembling  that  of  scarlet  fever;  the  tongue, 
moreover,  presents  an  appearance  similar  in  many  respects  to  the 
"  strawberry  "  tongue  of  scarlet  fever,  and  the  throat  shows  a  some- 
what similar  congestion. 

The  re?!iission. — In  from  twenty-four  to  forty-eight  hours  the 
first  eruption  disappears,  all  feverish  symptoms  subside,  and  for  a 
period  of  from  two  to  four  days  the  patient  feels  fairly  comfortable. 

The  secotid,  or  terminal  rubeolar  eruption. — A  return  of  fever, 
it  may  be  of  slight  amount  and  duration,  is  attended  by  a  recru- 
descence of  joint-aches  and  an  eruption  of  circular,  somewhat  elevated, 
discrete,  reddish  spots  on  the  hands,  wrists,  and  forearms ;  and  in  a 
few  hours  the  neck  and  face,  the  trunk,  and  finally  the  lower 
extremities  are  similarly  covered.  A  coalescence  of  spots  may  give 
the  eruption  an  urticarial  appearance,  or  even  cause  a  general  diffuse 
redness  of  the  skin.  In  a  day  or  two,  attended  by  a  profuse  sweat- 
ing, epistaxis,  or  an  intestinal  flux,  the  temperature  falls  to  the 
normal,  and  then  below  it.  Desquamation  of  a  furfuraceous  character 
succeeds,  and  for  some  twenty  days  the  patient  continues  to  shed 
the  epidermis  in  fine,  dusty  particles. 

Sequelse. — The  symptoms,  after  the  temperature  falls,  gradually 
fade  away  into  rheumatoid  pains,  at  times,  however,  of  a  distressing 
character,  attended  by  swollen  and  painful  joints.  Both  large  and 
small  joints  are  attacked,  and,  as  the  muscles  are  involved  in  the 
affection,  considerable  stiffness,  and  it  may  be  inability  to  move 
freely  induce  wasting  of  the  limbs  from  non-use.  Convalescence  is 
often  tedious,  except  in  the  case  of  children,  and  it  may  be  interrupted 
by  relapses  which  continue  the  disease  for  several  months. 

More  remote  sequelae  are — adenitis,  more  particularly  of  the 
cervical  glands  ;  orchitis  ;  albuminous  urine  ;  haemorrhage  from  nose, 
mouth,  bowels,  or  uterus ;  and  such  cutaneous  ailments  as  boils, 
pruritus,  and  evanescent  eruptions. 

Variety  in  t3rpe. — Dengue  in  some  cases  is  so  mild  in  type 
that  it  causes  the  patient  but  little  inconvenience.  A  slight  sore 
throat  with   some   pains   in   the  limbs  and  back,   and  a  feeling  of 


352  MANUAL  OF  MEDICINE 

lassitude  may  be  the  extent  of  the  symptoms.  Instead  of  the 
favourable  course,  however,  dengue  may  assume  a  serious  form ; 
the  skin  and  features  become  cyanotic,  collapse  supervenes,  and  the 
patient  dies  in  a  comatose  state.  This  form  constitutes  the  "  black 
fever "  of  Calcutta  natives.  Variations  occur  in  the  appearance  of 
the  rash,  which  at  times  is  scarcely  perceptible,  or  the  primary  rash 
may  be  rubeolar  in  character.  Children,  when  the  temperature 
runs  higli,  frequently  develop  delirium,  and  alarming  convulsions 
sometimes  usher  in  the  disease. 

Diagnosis. — In  tropical  countries  the  initial  symptoms  are  apt 
to  be  confounded  with  a  malarial  fever.  As  the  disease  advances 
influenza  suggests  itself;  but  the  appearance  of  the  rash  raises  the 
question  of  scarlet  fever  or  measles.  Influenza  is  frequently  con- 
founded with  dengue,  and  the  outbreak  of  the  modern  epidemic  of 
influenza  in  1888,  in  Hong-Kong,  was  at  first  regarded  as  being  one 
of  dengue,  the  more  so  as  in  many  cases  a  marked  rash  was  occa- 
sionally present.  Scarlet  fever  does  not  appear  in  epidemic  form  in 
tropical  countries.  Measles  occur  in  the  tropics,  but  it  seldom  attacks 
adults,  and  is  slow  in  its  progress  and  spread  compared  with  dengue. 
Prognosis. — An  attack  of  dengue  of  average  severity  justifies  a 
favourable  prognosis,  although  several  of  the  complications  and 
sequelae  in  the  young  or  old  may  lead  to  a  serious  or  a  fatal  issue. 
The  "black  fever"  of  Calcutta  already  referred  to  shows,  however, 
how  severe  dengue  may  become.  One  attack  of  dengue  confers 
some  degree  of  immunity  against  a  recurrence. 

Treatment. — In  all  respects  dengue  is  to  be  treated  as  other 
specific  eruptive  fevers,  such  as  scarlet  fever  or  measles.  The 
patient  is  to  be  confined  to  bed,  and  placed  on  the  usual  febrile 
regimen  as  to  diet.  Constipation  may  be  relieved  by  saline  aperients. 
Joint  and  muscular  pains  may  be  so  severe  as  to  require  the  external 
application  of  anodyne  liniments,  and  the  administration  of  morphia 
either  by  the  mouth  or  subcutaneously ;  the  tincture  of  belladonna, 
in  15  minim  doses,  repeated  thrice  at  intervals  of  one  hour,  has 
attained  a  reputation  as  a  means  of  allaying  the  suffering  peculiar  to 
dengue.  Cold  or  tepid  sponging  affords  considerable  relief  if  the 
temperature  be  high. 

Convalescence  may  be  usually  considered  to  commence  after 
the  tenth  day,  when  a  general  tonic  treatment  is  required. 

Isolation  of  the  sick  and  removal  of  exposed  persons  to  a  non- 
infected  house  or  district  affords  but  small  protection  when  dengue 
is  epidemic. 

James  Cantlie. 


BERl-BERI  353 


BERI-BERI 

A  specific  peripheral  polyneuritis,  characterised  by  disorders  of 
sensation,  paresis,  changes  in  the  electrical  response  of  the  muscles 
and  nerves,  and  widespread  vasomotor  disturbances  of  such  a  nature 
as  to  cause  either  a  general  anasarca  or  an  atrophic  appearance  of 
the  body.  The  disease  is  one  of  environment,  and  may  become 
endemic  in  localities  or  abodes.  It  is  usually  attended  by  a  high 
mortality,  death  resulting  from  exhaustion,  paralysis  of  the  heart,  or 
of  the  muscles  concerned  in  respiration. 

Geographical  distribution. — Originally  described  by  Bontius 
in  India,  the  disease  has  in  recent  years  been  scientifically  studied 
in  many  tropical,  sub-tropical,  and  even  temperate  climates,  more 
especially  in  Japan,  in  Brazil,  and  in  the  Dutch  East  Indies.  In 
addition  to  its  occurrence  in  these  several  countries  beri-beri  is  met 
with  in  the  southern  provinces  of  China,  in  Annam,  throughout 
Malaya,  Borneo,  Fiji,  New  Caledonia,  and  even  amongst  natives  of, 
and  the  Chinese  immigrants  in,  Australia.  In  America  it  is  found 
amongst  the  fishermen  of  the  North  Atlantic  sea-board,  in  Havana, 
at  Panama,  in  Brazil,  and  in  the  Sandwich  Islands.  In  Africa  cases 
have  been  met  with  from  the  neighbourhood  of  Lake  Nyassa  and 
the  Congo  (Manson).  Lastly,  attention  has  been  drawn  to  the 
disease  in  several  places  in  Europe,  more  especially  in  Ireland,  where, 
in  the  Richmond  Asylum,  Dublin,  during  1896,  1897,  and  1898,  a 
marked  outbreak  of  the  disease  has  been  described  by  Dr.  Conolly 
Norman. 

Etiology. — The  cause  of  beri-beri  has  not  yet  been  ascertained. 
A  bacterium  was  figured  and  described  by  Pekelharing  and  Winkler 
as  the  result  of  their  investigations  in  Java  and  Sumatra,  but  the 
specific  nature  of  the  organism  has  not  been  confirmed  by  subse- 
quent observers. 

A  diet  deficient  in  nitrogen,  such  as  rice,  especially  when  the 
grain  is  of  inferior  quality  and  deprived  of  its  outer  covering,  is  by 
many  competent  observers  held  to  be  associated  with  outbreaks  of 
beri-beri.  The  chief  reason  for  this  belief  is  that  a  change  to  a 
more  nitrogenous  diet  is  frequently  followed  by  the  disappearance 
of  the  disease.  In  the  Japanese  navy,  where  beri-beri  (kakke)  was 
very  frequent,  a  change  in  diet  of  the  kind  indicated  was  followed 
by  highly  satisfactory  results.  There  are  several  arguments  against 
VOL.  I  2  A 


354  MANUAL  OF  MEDICINE 

rice  being  a  direct  factor  in  the  etiology,  none  being  more  potent 
than  the  late  peculiarly  isolated  outbreak  in  the  lunatic  asylum  in 
Dublin.  By  some  the  disease  has  been  ascribed  to  the  consumption 
of  certain  species  of  fish  imperfectly  cooked. 

Of  other  assigned  causes  there  are  many.  Overcrowding, 
malaria,  climate,  angemia,  may  furnish  a  favourable  nidus  for  an 
outbreak  of  beri-beri  by  lowering  the  \dtality  and  diminishing 'the 
bodily  powers  of  resistance,  but  they  cannot  determine  the  onset  of 
a  disease  of  so  specific  a  character.  Beri-beri  is  essentially  the 
disease  of  environment  or  habitation.  It  would  seem  as  though  a 
dwelling  or  ship  became  infected,  and  that  the  disease  clung  to  the 
place.  As  a  consequence  healthy  persons  taking  up  their  residence 
in  quarters  vacated  by  beri-beri  patients  readily  become  infected. 

The  evidence  goes  to  show  that  beri-beri  is  dependent  upon  a 
toxic  influence,  probably  parasitic  in  nature,  having  its  habitat,  in 
all  probability,  outside  the  human  body.  The  disease  is  not  regarded 
as  directly  contagious,  nor  is  the  beri-beric  considered  to  be  personally 
infectious.  The  writer,  however,  found  what  appeared  to  be  direct 
communicability  take  place  in  a  hospital  for  Chinese  in  Hong- 
Kong.  A  number  of  cases  of  beri-beri  had  been  admitted  to  a 
general  ward,  and  after  a  time  beri-beri  developed  in  several  patients 
suffering  from  open  sores  in  the  same  ward,  whilst  it  passed  over 
those  who  showed  no  wounds.  Young  men  are  most  frequently 
the  subjects  of  beri-beri,  but  with  the  exception  of  infants  and  octo- 
genarians it  has  been  known  to  attack  persons  of  any  age  and  of 
either  sex.  The  rich  as  well  as  the  poor  suffer,  but  the  disease  is 
propagated  and  thrives  in  the  overcrowded,  insanitary  native  hovels, 
in  the  barracks  where  native  soldiers  congregate,  in  the  ill-con- 
structed, insanitar}',  and  crowded  temporary  dwellings  on  newly- 
opened  plantations.  Beri-beri  is  also  most  frequently  met  with  at 
low  levels,  and  more  especially,  but  by  no  means  exclusively,  along 
the  sea-coast. 

The  Dutch  observers  in  Sumatra  established  the  fact  that 
between  the  period  of  exposure  and  the  development  of  clinical 
signs  and  symptoms  of  the  disease,  or,  in  other  words,  during  the 
incubation  period,  careful  investigation  will  show  that  there  exist 
several  latent  signs.  Of  these  the  chief  are  a  slight  oedema  along 
the  crests  of  the  tibise,  and  important  variations  in  the  response  of 
the  muscles  and  nerves  to  electrical  stimuli.  The  minimum  period 
of  incubation  of  beri-beri  is  about  five  weeks.  The  maximum  period 
may  extend  over  several  months. 

Symptoms. — The  "invasion"  period  of  beri-beri — the  "initial 


BERI-BERI 


003 


phase  " — presents  the  following  signs  and  symptoms  : — slight  cedema 
along  the  tibial  crests ;  pale  and  swollen-looking  features ;  a  slight 
rise  in  temperature,  which  may  be  very  evanescent,  lasting  only  a 
few  hours,  but  nevertheless  none  the  less  constant ;  palpitation ;  a 
small,  irritable  pulse;  some  apparent  increase  of  cardiac  dulness ; 
violent  cardiac  impulse ;  a  prolonged  first  and  reduplicated  second 
sound  ;  shortness  of  breath  on  exertion  ;  difificulty  in  walking  quickly 
and  going  up  and  down  stairs  owing  to  muscular  stammering ; 
circumscribed  anaesthesia  and  pain  on  pinching  the  muscles  of  the 
lower  extremities. 

When  beri-beri  has  developed  there  will  always  be  found  in  the 
calf  of  the  legs  a  patch  which  is  insensible  to  a  light  touch,  and  to 
both  galvanic  and  faradic  currents.  The  leg  muscles,  and  after- 
wards the  muscles  of  the  thigh,  become  painful  when  pinched,  and 
the  anaesthetic  areas  increase  in  extent.  The  muscles  become 
weaker,  their  quantitative  irritability  is  diminished,  and  ver}"  slight 
resistance  is  sufficient  to  stop  extension  of  the  leg  and  flexion  of  the 
thigh.  The  muscles  of  the  calf,  when  contracted,  bulge  abnormally, 
but  although  painful  to  pressure  there  is  seldom  found  any  idio- 
muscular  contraction,  nor  are  they  usually  irritable  to  percussion. 
^Vhen  the  patient  attempts  to  rise  from  his  bed,  or  to  lie  down, 
considerable  awkwardness  is  noticeable,  and  when  he  attempts  to 
walk  the  gait  is  markedly  abnormal.  He  wavers  when  he  tries  to 
stand  with  his  eyes  closed,  nor  can  he  stand  on  tip-toe,  nor  on  one 
foot.  During  walking  the  patient  raises  the  foot  from  the  floor  with 
difficulty,  the  toes  leaving  the  floor  last,  and,  after  lifting  the  foot 
high  and  pushing  it  forwards,  suddenly  drops  it  on  the  floor.  The 
dynamometer  also  shows  that  the  muscular  power  of  the  hands 
and  arms  is  distinctly  lessened.  As  the  disease  progresses  the 
anaesthetic  areas  in  the  legs  may  extend  from  the  knee  along  the 
inside  of  the  limbs  to  the  heel ;  and  the  thenar  and  hypothenar 
eminences  in  the  hands  become  anccsthetic,  whilst  as  yet  the  parts 
of  the  hand  beyond  are  unaffected.  The  muscular  sense  is  un- 
disturbed, the  patient  localises  well  and  can  imitate  with  one  limb 
passive  movements  made  for  him  with  the  other.  The  condition  of 
the  reflexes  is  characteristic.  The  knee  jerk  completely  disappears, 
either  from  the  onset  of  the  initial  phase  or  after  a  few  days. 
Ankle  clonus  is  absent,  but  the  superficial  abdominal  and  scrotal 
reflexes  are  readily  elicited.  The  muscles,  more  especially  those 
supplied  by  the  external  popliteal  nerve,  exhibit  the  reaction  of 
partial  degeneration.  Irritability  to  the  faradic  current  is  sup- 
pressed, whether  the  current  is  applied  directly  or  indirectly,  and 


356  MANUAL  OF  MEDICINE 

there  is  also  diminution  of  direct  and  indirect  irritability  to  the 
galvanic  current.  The  subsequent  symptoms  depend  largely  on 
the  seat  of  the  nerves  attacked. 

The  dilated  heart  may  give  out,  or  this  condition,  combined 
with  a  sudden  effusion  into  the  pericardium,  may  cause  cyanosis, 
dyspnoea,  or  syncope.  The  respiratory  muscles,  on  the  other  hand, 
may  become  paralysed,  causing  sudden  death  by  asphyxia.  Vomit- 
ing is  a  grave  sign,  and  death,  when  it  occurs,  is  usually  sudden.  In 
favourable  cases  the  oedema,  if  it  exists,  disappears,  the  paralytic 
signs  are  first  stayed  in  their  advance  and  then  abate  in  their 
intensity.  Power  returns  to  the  hands  and  legs,  the  irritabiUty  of 
the  heart  lessens,  dyspnoea  disappears,  and  after  three  months  or  so 
the  patient  is  usually  able  to  get  about,  or  even  follow  his  employ- 
ment. Occasionally  it  happens  that  paresis  remains  for  an  indefinite 
period.  During  the  development  of  these  paralytic  signs  and 
symptoms  the  general  health  of  the  patient  is  wonderfully  good. 
The  digestive  organs  present  nothing  amiss,  and  the  urine  seldom 
betrays  any  signs  of  renal  disturbance. 

Vapieties. — The  three  most  pronounced  types  of  beri-beri  are 
the  oedematous,  wet,  moist,  dropsical;  the  atrophic,  dry;  and  the 
mixed.  In  addition  to  these  names,  however,  we  are  familiar  with 
such  terms  as  "acute"  and  "chronic"  beri-beri,  "foudroyante,"  etc. 
It  is  doubtful  whether  any  one  of  these  is  worthy  of  the  name  of  a 
variety,  as  it  is  possible  the  one  is  but  the  precursor  or  sequel  of 
another,  a  mere  predominant  symptom  being  seized  upon  to 
constitute  the  basis  of  differentiation. 

1.  The  (edematous,  dropsical,  '■'■wet''''  or  ^^  moist"  form  of  beri- 
beri is  characterised  by  a  fairly  general  oedema.  The  anasarca 
closely  resembles  that  met  with  in  a  case  of  acute  Bright's  disease, 
but  the  urine,  although  presenting  occasionally  a  slight  albuminous 
cloud  on  boiling,  shows  none  of  the  characteristic  features  con- 
sequent on  acute  nephritis.  The  oedema  is  at  times  partial,  often 
missing  the  scrotum,  and  at  times  changing  its  site.  The  serous 
cavities  may  be  the  seat  of  a  large  amount  of  effusion,  the  peri- 
cardial cavity  being  especially  liable  to  effusion  ;  but  the  pleural 
cavities  may  be  filled  to  such  an  extent  that  breathing  is  greatly 
hampered  and  the  lung  space  so  dimmished  that  asphyxia  super- 
venes. 

2.  The  atrophic,  '■'■dry,"  or purefy paraplegic  variety  of  beri-beri  is, 
as  the  names  imply,  associated  with  shrinking  of  the  tissues  of  the 
body.  The  muscles  are  flabby  and  the  fat  of  the  body  disappears. 
The  patient,  as  regards  his  alimentary  and  renal  condition,   may 


BERI-BERI  357 

be  pronounced  healthy,  and  it  is  to  a  paralysis  of  the  laryngeal  or 
respirator)'  muscles  that  he  usually  succumbs. 

3 .  Atrophic  and  cedematous — ' '  mixed ' ' — beri-beri.  — When  atrophic 
symptoms  are  obscured  by  serous  effusion  into  the  muscular 
and  the  connective  tissues,  and  when,  also,  the  serous  cavities  are 
the  seat  of  a  similar  effusion,  the  cHnician,  pledged  to  the  cognisance 
of  a  "  wet  "  and  a  "  dry  "  variety  of  beri-beri,  will  find  great  difficulty 
in  referring  the  disease  to  its  particular  variety.  Hence  the  adoption 
of  the  term  "  mixed,"  in  which  the  signs  and  symptoms  of  the  "  wet  " 
and  "  dry  "  varieties  are  combined. 

In  all  these  divergencies,  however,  one  symptom  remams  con- 
stant, viz.  the  electrical  modifications  of  the  ner\'es  and  muscles. 
It  would  be  well  to  dispense  with  these  distinctions,  except  in  so  far 
as  they  indicate  stages  in  the  disease,  because  oedema  is  only  a 
secondary  phenomenon,  and  if  the  mixed  form  is  taken  as  the  type, 
the  dropsical  and  dry  forms  are  but  a  quantitative  modification 
of  it. 

The  motor  disordeis. — The  most  constantly  paralysed  muscles  are 
the  groups  supplied  by  the  external  popliteal  nerves,  viz.  the 
peronei,  and  the  extensors  of  the  toes  ;  the  next  most  frequently 
affected  muscles  are  the  flexors  of  the  toes.  The  extensors  of  the 
knee  and  the  gluteal  muscles  are  also  liable  to  be  involved  in  the 
paresis,  whilst  the  adductors  and  the  knee  flexors  escape.  In  the 
upper  extremities  the  extensors  of  the  hand  and  fingers,  the  supinator 
longus,  the  triceps,  the  flexors  of  the  hand  and  fingers  are,  in  the 
order  given,  the  muscles  liable  to  attack.  In  addition  to  these  the 
abdominal  muscles,  the  diaphragm,  and  the  intercostal  muscles 
suffer.  Even  the  muscles  supplied  by  the  cranial  nerves  may 
become  involved  ;  the  muscles  of  expression  and  the  muscles  of 
the  eyeball  having  been  known  to  become  paralysed.  The  laryngeal 
muscles  are  also  frequently  involved,  with  the  result  that  sudden 
death  ensues  from  asphyxia. 

Disorders  of  sensory  nerves. — The  sense  of  touch  is  first  lost  on 
the  inner  aspect  of  the  calf  of  the  leg,  then  on  the  dorsum  of  the 
foot,  and  finally  sensation  may  be  lost  everywhere  below  the  knee. 
In  the  upper  extremities  sensation  disappears  first  on  the  anterior 
aspect  of  the  wrist,  then  over  the  thenar  and  hypothenar  eminences, 
and  finally  over  other  parts  of  the  hand ;  the  ends  of  the  fingers 
being  the  last  places  from  which  it  vanishes.  Anaesthesia  may  over- 
take the  whole  of  the  upper  limb  as  far  as  the  shoulders.  Ansesthetic 
areas  may  also  be  met  with  over  the  anterior  aspect  of  the  trunk, 
reaching  as  low  as  the  umbilicus, 


358  MANUAL  OF  MEDICINE 

Heart  affections. — The  heart  is  early  affected  in  beri-beri.  Not 
only  are  there  marked  subjective  symptoms,  but  there  is  a  pro- 
nounced enlargement  of  the  cardiac  area,  especially  towards  the 
right,  and  pathological  evidence  shows  that  there  is  hypertrophy 
accompanied  by  dilatation  of  the  right  ventricle.  The  state  of 
the  ventricle  explains  the  dropsical  effusion  into  the  tissues  and  the 
serous  cavities  and  the  other  effects  of  venous  obstruction. 

Post-mortem  appearances. — According  to  the  type  of  beri- 
beri which  has  proved  fatal,  so  do  the  post-mortem  evidences  vary. 
In  the  "  wet  "  variety  serous  effusions  may  be  found  in  the  sub- 
cutaneous and  intermuscular  tissues  and  in  the  serous  cavities  of  the 
body  ;  in  the  "  dry  "  variety,  on  the  other  hand,  the  muscles  when 
cut  into  reveal  the  yellowish- brown  colour  characteristic  of  atrophy. 
It  must  be  remembered,  however,  that  oedema  to  some  extent  has 
always  existed  at  some  period  of  the  disease,  and  pericardial 
effusion  in  particular  is  one  of  the  most  constant  features  of  beri- 
beri. It  is  in  the  heart  itself,  however,  that  pathological  change  is 
to  be  sought  for.  Hypertrophy  of  the  right  ventricle  is  always 
present,  accompanied  by  a  dilatation  var)'ing  from,  it  may  be  a  small, 
to  an  enormous  extent.  The  heart  muscle  is  often  pale,  but 
microscopic  examination  shows  that  this  is  not  usually  due  to 
fatty  degeneration.  Of  the  other  organs  the  lungs  may  be  cedema- 
tous,  the  liver  congested,  the  spleen  increased  in  bulk  and  weight, 
and  the  blood  in  the  large  veins  in  a  fluid  state.  The  examination 
of  the  nervous  system  shows  that,  in  the  nerves  generally,  a  state  of 
peripheral  neuritis  and  nerve  degeneration  exists,  and  that  the 
lesion  diminishes  in  intensity  as  the  centre  is  approached.  The 
anterior  roots  of  the  spinal  nerves  show  no  pathological  change, 
but  in  the  posterior  roots,  more  especially  in  the  part  between  the 
ganglion  and  the  nerve  trunk,  atrophied  fibres  are  met  with.  In 
the  central  nervous  system  the  most  constant  change  is  an  alteration 
(it  may  be  an  atrophy)  in  the  large  cells  occupying  the  anterior 
cornua  of  the  spinal  cord. 

Prognosis. — During  an  attack  of  beri-beri  it  is  well-nigh  im- 
possible to  venture  on  a  prognosis  ;  for  cases  of  seeming  mildness 
prove  fatal,  whilst  cases  of  apparently  a  severe  type  recover.  In 
general  about  20  per  cent  of  those  attacked  die;  but  the  numbers 
vary,  it  may  be  as  much  as  i  o  or  even  1 5  per  cent  either  wa)'.  Un- 
favourable signs  are :  cardiac  and  vascular  changes,  such  as  a  quick 
and  feeble  pulse,  epigastric  pulsation,  throbbing  of  the  blood  vessels 
in  the  neck  and  increase  in  the  cardiac  area ;  extensive  serous 
effusions  into  the  peritoneal,  pleural  or  pericardial  cavities ;  failure 


BERI-BERI  359 

in  power  of  the  respiratory  muscles ;  marked  diminution  in  the 
quantity  of  urine  passed ;  and  vomiting.  The  last  -  mentioned 
feature  supervening,  as  it  sometimes  does  during  the  course  of  an 
acute  attack  of  beri-beri,  is  a  very  unfavourable  sign. 

Diagnosis. — Beri-beri  has  to  be  diagnosed  from  peripheral 
neuritis,  due  to  alcohol  or  to  malaria,  from  locomotor  ataxy,  and  from 
epidemic  dropsy.  In  epidemic  forms  of  the  disease  the  diagnosis 
is  readily  enough  arrived  at,  but  when  sporadic  cases,  or  when  even 
limited  outbreaks  occur  in  what  are  regarded  as  non-beri-beric 
countries,  as  in  Ireland,  the  recognition  of  the  disease  is  attended  by 
obvious  difficulties.  Reliance  must  be  placed  upon  the  presence  of 
oedema,  limited,  it  may  be,  to  the  front  of  the  shins  ;  upon  the 
absence  of  knee  jerk ;  upon  the  tumbling  action  of  the  heart ;  pain 
on  pinching  the  limb  muscles  and  patches  of  anaesthesia  on  the 
legs  and  perhaps  the  arms.  If  electrical  testing  is  available  the 
diagnosis  is  greatly  facilitated. 

Treatment — Prophylaxis. — Seeing  that  beri-beri  is  a  disease  of 
environment  it  is  necessary  to  correct  or  alter  th6  immediate 
surroundings  of  those  exposed  to  the  disease.  Disinfecting  the 
abode,  the  furniture,  and  the  clothing  of  beri-berics  serves  to  check 
the  numbers  of  those  attacked;  but  it  is  only  by  evacuating  the 
premises,  and  it  may  be  leaving  the  locality  where  beri-beri  is 
endemic,  that  an  outbreak,  say,  amongst  troops '  in  barracks,  coolies 
in  coolie  quarters,  and  prisoners  in  a  jail,  may  be  stamped  out.  In 
the  case  of  the  individual  it  is  only  by  removal  to  an  untainted 
locality  that  a  cure  can  be  confidently  hoped  for. 

Rest  in  bed  ought  to  be  insisted  upon  and  sudden  movement  or 
exertion  forbidden.  The  diet  must  be  liberal  in  the  item  of 
nitrogenous  elements,  and  if  rice  has  been  the  staple  food  heretofore 
it  should  be  supplanted  by  bread,  meat,  milk,  and  fresh  vegetables. 
When  it  is  impossible  to  immediately  quit  the  abode,  as  on  board 
ship,  those  afflicted  with  beri-beri  should  be  granted  the  best  sleeping 
accommodation  possible,  and  during  the  day  should  be  brought  out 
into  the  open  air. 

The  state  of  the  heart  and  of  the  circulatory  organs  generally  calls 
for  medicinal  treatment.  Cardiac  stimulants,  such  as  digitalis,  may 
be  administered  with  good  effect ;  nitroglycerine  in  the  form  of  the 
liquor  trinitrini  (i  min.),  or  tabellce  nitroglycerini  B.P.  (i  tablet) 
should  be  at  hand  for  emergencies  of  cardiac  failure.  Amyl  nitrite 
may  be  inhaled  from  a  crushed  capsule  with  the  same  intention. 
The  functional  condition  of  the  heart  in  beri-beri  is  so  little  under- 
stood that  it  is  difficult  to  justify,  far  less  to  explain  the  beneficial 


36o  MANUAL  OF  MEDICINE 

action  of  these  drugs,  except  it  be  that  by  the  administration  tem- 
porary relief  is  afforded  to  the  enlarged  right  ventricle,  by  diminishing 
the  resistance  of  the  blood  vessels  to  the  onward  passage  of  the 
blood. 

Aspiration  of  first  one,  and  (if  necessar}')  later  the  other  pleural 
cavity  affords  relief  in  dyspnoea,  and  the  writer  found  benefit  by 
venesection  in  one  case  of  threatened  asphyxia  and  by  aspiration  of 
the  pericardial  effusion  in  another. 

\\'hen  the  patient  is  convalescing  strychnine  is  the  best  medicinal 
tonic ;  but  massage,  electrical  stimulation  and  general  tonic  treat- 
ment favours  recover)'.  It  was  at  one  time  believed  that  beri-beri 
always  relapsed,  and  that  in  about  twelve  months  a  recrudescence  was 
to  be  looked  for.  No  doubt  this  is  the  case  when  the  patient 
returns  to  an  infected  environment,  but  by  residence  in  a  healthy 
locality  such  a  relapse  may  be  almost  certainly  avoided. 

James  Cantlie. 


EPIDE^IIC  DROPSY 

An  epidemic  disease  of  variable  mortality  and  lasting  from  three 
to  six  weeks ;  characterised  by  oedema  of  the  lower  extremities  or 
of  the  entire  body,  accompanied  by  pyrexia,  by  gastric  and  intestinal 
irritation,  by  aching  in  the  limbs  and  trunk,  and  frequently  by  a 
cutaneous  rash  of  a  rubeolar  appearance. 

Geographical  distribution. — Since  Dr.  Kenneth  M'Leod 
first  described  the  disease  in  Calcutta  in  1877,  several  observers 
have  recorded  outbreaks  of  the  disease.  In  Assam,  in  Lower 
Bengal,  and  in  Mauritius,  well-defined  occurrences  have  taken 
place,  and,  in  all  probability,  outbreaks  of  this  particular  malady 
have  developed  at  several  places  on  the  littoral  of  the  Indian 
Ocean. 

Etiology. — Epidemic  dropsy  appears  to  be  communicable 
from  one  member  of  the  community  to  another,  and  is  mainly  con- 
fined to  the  adults  of  both  sexes  of  a  family.  It  occurred  in 
Calcutta  during  the  cold  weather,  disappeared  completely  during 
the  hot  season,  and  for  three  successive  winters,  1887  to  1890, 
recurred  persistently ;  since  then  the  disease  does  not  seem  to 
have  re-appeared,  Nq  European  is  known  to  have  contracted  the 
disease. 


EPIDEMIC  DROPSY  361 

No  bacteriological  investigations  have  been  as  yet  communicated 
concerning  the  causation  of  epidemic  dropsy. 

Symptonis. — Initial  symptoms  vary.  In  some  instances  the 
disease  is  ushered  in  by  the  dropsical  effusion ;  in  others,  fever  first 
attracts  attention  ;  or  again  general  malaise  or  intestinal  flux  precede 
all  other  manifestations. 

The  oedema  appears  in  the  feet  and  ankles  and  may  extend 
beyond  the  lower  extremities  to  the  whole  body,  sometimes  lasting 
for  a  considerable  period.  Pleural  and  pericardial  effusions  have 
sometimes  been  noticed.  Fever  may  usher  in  the  symptoms,  may 
accompany  the  dropsy  or  appear  only  during  its  subsidence.  It  is 
seldom  the  thermometer  registers  higher  than  102°.  Vomiting  is 
seldom  distressing ;  diarrhoea  or  even  dysentery  of  a  mild  type  occa- 
sionally occurs.  In  addition  to  itching  and  burning  of  the  skin,  a 
general  exanthematous  rasli,  of  a  rubeolar  character,  is  a  common, 
but  by  no  means  a  constant,  accompaniment.  The  general  signs 
and  symptoms  include  a  weakened  pulse,  breathlessness,  and  marked 
ansmia  and  prostration.  Nocturnal  pains  in  the  hmbs  have  been 
frequently  observed. 

Occasional  signs  and  symptoms  of  pneumonia,  oedema  of  the 
lungs,  cardiac  dilatation,  scurvy,  and  albuminous  urine  have  all  been 
recorded  as  complications  of  the  disease. 

Diagnosis. — The  only  disease  likely  to  be  confused  with  epi- 
demic dropsy  is  beri-beri.  In  fact  many  observers  positively  assert 
their  identity ;  whilst  on  the  other  hand  it  is  possible,  nay  probable, 
that  many  cases  at  present  classed  as  beri-beri  will  prove  to  be  of  the 
nature  of  epidemic  dropsy.  The  one  characteristic  feature  of  beri- 
beri which  serves  definitely  to  stamp  its  specific  nature  is  the  nervous 
and  paralytic  affections,  and  these  are  absent  in  epidemic  dropsy. 
Moreover,  beri-beri  is  more  chronic  and  never  complicated  by  a 
cutaneous  eruption,  nor  is  fever  a  prominent  feature. 

Mortality. — -In  the  Calcutta  epidemics  a  death-rate  of  from 
twenty  to  forty  per  cent  of  those  attacked  occurred.  On  the  other 
hand,  in  the  Assam  outbreak,  no  fatal  cases  were  known. 

Treatment. — Such  remedial  treatment  as  a  weakened  circula- 
tion demands,  and  as  is  appropriate  in  urgent  cases  of  dyspnoea 
or  apnoea  is  called  for  in  the  treatment  of  epidemic  dropsy. 

Southey's  trocars  are  indicated  as  a  means  of  relieving  the 
dropsical  effusion,  and  even  aspiration  of  the  pleura  or  pericardium 
may  be  necessary.  During  convalescence  anaemia  is  the  most 
prorninent  condition  which  requires  treatment. 

James  Cantlie, 


362  MANUAL  OF  MEDICINE 


ORIENTAL  SORE 
Syn.  Delhi  Boil  ;  Bagdad  Sore  ;  Biskra  Button  ;  Aleppo  Evil 

A  specific  inflammatory  affection  of  the  deeper  layers  of  the 
skin,  which,  commencing  as  a  papule,  soon  crusts  over,  and  spread- 
ing by  phagedsena,  develops  an  ulcer  of  an  indolent  character. 
The  healing  is  protracted,  and  a  permanent  scar,  a  "  date  "  mark, 
remains  to  indicate  the  seat  of  the  affection. 

Geographical  distribution. — The  various  synonyms  indicate 
the  principal  places  in  which  this  peculiar  affection  is  met  with.  In 
Europe,  Greece  and  Crete  seem  to  be  the  only  countries  in  which 
the  disease  has  been  noted.  In  Africa  it  occurs  in  Morocco,  Egypt, 
and  certain  parts  of  the  Sahara.  In  Asia:  Bagdad  in  'Mesopotamia, 
Aleppo  in  Syria,  Delhi  and  Mooltan  in  India,  are  the  chief  seats 
of  the  disease.  But  Arabia,  Persia,  and  Turkestan  are  known  also 
to  harbour  the  malady.  Some  ten  years  ago  persons  residing  in  tlie 
town  of  Bahia,  Brazil,  were  declared  to  be  affected  with  true 
"Oriental  Sore." 

What  the  specific  infective  matter  may  be  is  unknown.  Objects 
that  appear  to  be  minute  parasites  in  the  "  boil "  have  been  described 
by  Dr.  Smith  as  the  ova  of  Distoma,  by  Dr.  V.  Carter  as  the 
spheroids  and  mycelium  of  a  special  parasite,  and  by  Dr.  Cunning- 
ham as  zoocysts  or  sporocysts  which  are  also  met  with  in  the  water 
in  some  of  the  districts  where  Oriental  sore  is  endemic.  Biting 
insects  are  in  all  probability  the  carriers  of  the  infectious  matter,  as 
it  is  the  exposed  parts  of  the  body  that  are  almost  solely  attacked. 

Etiology. — It  would  seem  as  though  a  special  state  of  climate  and 
constitution  were  necessary  for  the  development  of  the  disease,  as  it 
occurs  in  countries  possessing  for  the  most  part  a  dry,  even  arid, 
climate,  and  it  appears  towards  the  end  of  the  hot  season,  when  the 
vigour  of  those  attacked  is  probably  at  its  lowest.  Insanitary  surround- 
ings favour  the  development  of  Oriental  sore.  All  nationalities,  both 
sexes  and  all  ages,  are  liable  to  attack,  and  the  disease  seems  to 
occur  in  special  prevalence,  not  only  at  certain  seasons,  but  also 
during  certain  years. 

One  attack  as  a  rule  confers  a  permanent  immunity. 

Communicability. — The  disease  is  not  confined  to  human 
beings.      Dogs  and   horses  are  stated  by  Fayrer  to  suffer  from  a 


ORIENTAL  SORE  363 

disease  in  India  closely  resembling  Oriental  sore.  Both  man  and 
the  lower  animals  can  be  inoculated  by  discharge  from  the  surface 
of  ulcers.  Attempts  at  inoculations  from  cultures  of  certain  micro- 
cocci obtained  from  the  centre  of  the  papules  have  hitherto  failed. 

Symptoms. — On  some  exposed  part,  or  parts,  of  the  body, 
usually  the  face,  neck,  or  extremities,  the  attention  of  the  patient  is 
drawn  to  a  small  itching  papule,  or  to  a  number  of  similar  pimples  on 
different  parts  of  the  body.  When  looked  at  carefully  the  papule 
appears  pink  in  colour ;  it  is  frequently  situated  around  a  hair 
follicle,  and  the  epidermis  over  it  is  seen  to  be  dry  and  loose. 
Gradually  the  subcutaneous  tissues  around  become  infiltrated  and 
feel  boggy  to  the  touch ;  the  intense  itching  alternates  with  occa- 
sional stinging  pains ;  and  a  slight  oozing  from  the  surface  and 
moistening  of  the  skin  causes  the  epidermal  cells  to  cake,  and 
finally  to  crust.  Underneath  the  crust  an  ulcerating  surface 
develops,  at  first  quite  superficially,  but  gradually  the  ulceration 
extends  deeper  and  wider,  presenting  a  rather  sharply  cut  and 
indurated  edge.  The  crusts  fall  and  re-form  from  the  thin  ichorous 
material  which  exudes.  Around  the  primary  papule  others  form, 
and,  as  these  coalesce,  they  add  to  the  extent  and  intractability 
of  the  sore.  An  individual  sore  is  usually  about  one  inch  in 
diameter,  and  there  may  be  several  on  different  parts  of  the  body. 
It  is  believed  also  that  any  ordinary  boil  or  wound  may  take  on  the 
characters  peculiar  to  Oriental  sore.  After  many  weeks,  or  more  likely 
months,  the  wound  shows  signs  of  healing.  Slow  in  its  development, 
however,  the  "  sore  "  is  still  slower  in  its  disappearance,  and  it  leaves 
behind  the  peculiar  "  date  "  scar,  indelibly  impressed.  The  cheek 
and  nose  are  favourite  sites  of  the  disease,  and  a  large  "  date  "  mark 
on  either  of  these  may  be  followed  by  permanent  unsightliness. 

Prognosis. — There  is  but  little  danger  to  life  from  Oriental 
sore.  Were  the  wound  to  be  attacked  by  erysipelas,  or  become 
markedly  phagedaenic,  alarming  symptoms  might  ensue. 

Treatment. — Destruction  by  caustics  or  cautery  of  the  primary 
seat  of  infection  has  been  frequently  attempted,  but  the  results  are 
not  encouraging ;  and  in  the  absence  of  any  known  specific  appli- 
cation, it  is  wiser  to  pursue  an  expectant  treatment,  viz.  attending 
to  the  general  health,  seeing  to  the  sanitation  of  the  house  and 
environment,  applying  soothing  antiseptic  remedies  to  the  sore 
whilst  it  is  indurated  and  irritable,  and  promoting  healing  by 
cleansing  the  wound  and  protecting  its  surface. 

James  Cantlie. 


364  MANUAL  OF  MEDICINE 


VERRUGA  PERUANA 

A  specific,  general,  infective,  inoculable  disease,  characterised  by 
constitutional  symptoms  and  a  special  granulomatous  eruption.  It 
seems  to  be  quite  distinct  from  framboesia. 

The  disease  is  peculiar  to  certain  defiles  penetrating  the  tropical 
Andean  mountainous  districts  of  the  departments  of  Ancache  and 
Lima,  which  are  watered  by  rivers  overflowing  each  January  and 
June.  There  are  no  limitations  as  to  age,  sex,  or  race.  Domestic 
animals,  such  as  dogs,  pigs,  fowls,  turkeys,  horses,  mules,  llamas, 
cows,  and  asses  contract  the  disease,  which  assumes  remarkable 
proportions  in  the  solipeds. 

Eight  to  forty  days  are  generally  allowed  to  be  the  incubation 
period  ;  some  observers  give  even  a  longer  range. 

The  invasion  symptoms  may  be  of  very  different  degrees  of 
severity.  The  malady  may  be  so  intensely  virulent  that  the  patient 
succumbs  before  the  eruption  appears.  Usually  there  is  an  in- 
sidious onset  with  general  malaise,  which  gradually  becomes  inten- 
sified. Pain  and  fever  are  prominent.  Rheumatoid  pains,  with 
nocturnal  exacerbations,  shift  from  joint  to  joint,  and  are  often 
terribly  severe.  Muscular  pains,  also,  may  produce  rigidity  and 
contractions.  A  great  variety  of  febrile  types  are  observed,  of  which 
the  acute  arthritic  and  low  typhoid  may  be  especially  noted.  '  The 
fever  may  be  intermittent,  and  is  generally  hectic ;  the  intensity 
corresponds  with  the  virulence  of  the  infection.  A  marked  ansemia 
sets  in,  with  profound  prostration,  and  these  states  are  apt  to  be 
increased  by  the  subsequent  ulceration  and  bleeding  of  the  eruption. 
Hgemic  murmurs  may  develop,  serous  effusions  are  frequent,  and 
the  spleen,  and  sometimes  the  liver,  enlarges.  The  eruption  appears 
after  a  period  of  twenty  days,  or  only  after  six  or  eight  months,  or 
even  one  year,  it  is  said,  and  when  it  evolves  the  general  symptoms 
tend  to  abate.  Its  duration  may  be  put  at  about  two  to  eight  months, 
but  varies  widely  according  to  the  number  of  outbursts,  and  the 
quantity  and  volume  of  the  elements  and  attending  complications. 
It  appears  usually  in  the  skin  of  the  extremities  and  face,  and  spreads 
thence  to  more  or  less  of  the  rest  of  the  body,  and  to  the  mucous 
membranes,  and  even  the  splanchnic  organs  and  serous  membrane. 
The  distribution  is,  however,  most  variable.  The  eruptive  elements 
may  be  small  and  superficial,  or  develop  more  deeply  in  the  cutis 


FRAMBCESIA  365 

and  subcutaneous  tissue,  and  then  attain  the  size  of  an  orange,  or 
more,  and  give  rise  to  grave  cachexia  by  their  sloughing  and  bleeding. 
The  smaller  type  begins  as  a  tiny  red  spot,  which  develops  into  an 
itching,  shining  papule,  and  finally  into  a  very  vascular,  red  "  wart " 
(whence  the  name  verruga),  which  may  become  pedunculated.  The 
eruptions  gradually  die  away  with  exfoliation  or  bleeding,  or  ulcera- 
tion and  crusting.  Histologically  the  granulomata  are  said  to  bear  a 
striking  resemblance  to  sarcomata,  and  to  be  specially  characterised 
by  a  remarkable  vascularity.  According  to  Yzquierdo,  they  are 
caused  by  a  specific  bacillus,  which  is  found  between  the  cells,  and 
also  thrombosing  the  vessels. 

The  diagnosis,  in  the  pre-eruptive  stages  from  malaria,  rheu- 
matic and  typhoid  fevers,  is  often  very  difficult.  Verruga  is  a  very 
serious  and  dangerous  affection. 

There  is  no  specific  treatment  known  to  be  effective.  The 
sufferer  should  be  removed  at  once  to  as  healthy  a  locality  as  possible 
at  the  sea  level. 

T.  CoLCOTT  Fox. 


FRAMBCESIA 


A  highly  contagious,  but  not  hereditary,  specific,  general, 
chronic,  infective  disorder,  characterised  by  a  cutaneous  granulo- 
matous eruption  of  special  aspect,  resembling  a  raspberry,  whence 
the  name  is  derived  through  the  French  "  framboise."  It  is  endemic 
in  some  of  the  West  Indian  Islands  ("yaws  "'),  especially  Dominica  ; 
in  parts  of  Brazil  and  the  Spanish  South  American  colonies 
("bubas")  and  Guiana;  in  Fiji  ("koko  "),  Loyalty,  New  Caledonia, 
and  other  Melanesian  Islands;  in  Ceylon  ("  paranghi "),  along  the 
Coromandel  Coast,  Assam,  and  the  East  Indies  ;  in  the  Moluccas, 
the  East  Coast  of  Africa,  along  the  Mozambique  Channel,  and 
on  the  West  Coast  about  Sierra  Leone.  One  attack  renders  the 
subject  immune  for  the  most  part.  It  is  not  syphilis  altered  by 
race,  climate,  and  locality,  for  both  diseases  breed  true  in  the 
same  community ;  syphilis  can  be  inoculated  and  run  a  typical 
course  in  a  yaws  subject,  and  healthy  children  are  born  of  women 
actually,  or  recently,  suffering  from  yaws.  Moreover,  the  incubation 
stages  are  different,  and  many  of  the  secondary  symptoms  character- 
istic of  syphilis,  such  as  iritis,  sore  throat,  and  usually  the  adeno- 


366  MANUAL  OF   MEDICINE 

pathy,  are   absent.     Tertiary  symptoms   do   not   follow,  it   is   said, 
though  ulceration  is  not  unfrequent. 

Inoculation  occurs  through  any  of  the  breaches  of  surface,  so 
frequent  in  unclothed  people  living  under  unhygienic,  crowded, 
miserable  conditions. 

After  an  incubation  period,  variously  stated  from  two  to  ten 
weeks,  or  a  somewhat  shorter  average  time  (twelve  to  twenty  days) 
in  experimental  inoculations,  an  initial  papule  appears  at  the  seat 
of  inoculation  in  a  considerable  proportion  of  cases,  though  not 
invariably,  and  develops  into  a  moist,  yellow,  fungating  granuloma, 
similar  to  those  of  the  generalised  eruption,  and  sometimes  persist- 
ing for  a  long  period  as  the  "  mother-yaw."  Simultaneously  with 
the  initial  papule,  or  shortly  after,  but  usually  within  ten  days,  a 
granulomatous,  more  or  less  generalised,  eruption  appears  in 
successive  crops,  and  may  last  as  a  whole  from  three  months  to  four 
years,  averaging  about  two  years.  The  eruption  evolves  as  itching 
papules,  the  size  of  pin-heads,  which  may  abort  in  the  early  stages 
with  the  separation  of  corresponding  scales.  Some  authors  draw 
special  attention  to  the  occurrence  of  such  furfuraceous  desquama- 
tion in  the  earlier  stages  of  the  effection  or  at  later  periods.  As  a 
rule  the  enlarging  papule  bursts  through  the  epidermis  and  discloses 
a  central,  yellowish,  softened  point  which  may  simulate  a  pustule. 
Finally,  an  abruptly -raised,  painless  excrescence  is  formed  like 
"  proud  flesh,"  or  somewhat  resembling  mucous  tubercles  or  condy- 
lomata, or,  in  certain  rarer  dry  states,  warts.  These  efflorescences  may 
reach  the  size  of  a  small  pea,  or  even  a  walnut,  and  may  form 
larger  patches  by  confluence,  or  become  annulate.  They  tend  to 
be  covered  with  a  thin  scab,  and  on  disappearance  after  some  weeks 
leave  a  stain  lasting  a  few  or  many  months.  In  many  cases  succes- 
sive crops  continue  to  appear.  The  eruption  may  be  generalised 
and  copious,  or  scanty  and  localised.  The  lips  and  nostrils  may  be 
implicated,  but  otherwise  the  mucous  membranes  appear  to  escape, 
as  do  the  viscera.  In  the  conditions  under  which  framboesia  occurs 
it  is  not  surprising  that  secondary  ulcerations  should  result  in  many 
cases.  The  causal  micro-organism  has  not  yet  been  definitely 
established. 

Constitutional  symptoms,  such  as  fever,  are  absent,  slight,  or  rarely 
severe,  and,  as  a  rule,  the  subjects  continue  their  usual  avocations. 

Treatment. — Isolation  is  necessary  to  prevent  the  spread  of 
the  disease.  In  ordinary  cases,  where  the  general  health  is  good, 
the  disease  runs  its  natural  mild  course  under  proper  feeding  and 
hygiene,  and  the  prognosis  is  most  favourable.      Mercury  and  iodide 


SYPHILIS  367 

of  potassium  have  been  much  used,  and  the  reports  as  to  their  action 
are  most  conflicting.  The  local  application  twice  daily  of  chromic 
acid,  or  a  mixture  of  picric  and  carbolic  acid  to  dry  up  the  granulo- 
mata  is  recommended ;  and  for  some  of  the  later  and  more  per- 
sistent lesions  nitrate  of  silver  and  sulphate  of  copper  are  useful. 

T.  CoLCOTT  Fox. 


SYPHILIS 


Syphilis  is  a  specific  contagious  disease,  communicable  by  direct 
inoculation.  Its  course  is  characterised  by  a  primary  lesion  (chancre), 
by  early  constitutional  (secondary)  symptoms,  and  by  late  constitu- 
tional (tertiary)  symptoms. 

Frequently  a  final  stage  is  to  be  observed,  a  post -syphilitic  fibrosis, 
especially  well  marked  in  the  blood  vessels,  nervous  tissues,  and  bones, 
in  which  there  is  an  overgrowth  of  the  connective-tissue  elements  of 
those  structures,  the  fibrous  overgrowth  being  such  that  although  it 
appears  to  be  the  result  of  the  continued  action  of  the  syphilitic 
virus,  yet  it  refuses  to  yield  to  the  usual  anti-syphilitic  remedies. 
For  this  reason  some  authorities  do  not  regard  it  as  an  integral  part 
of  the  syphilitic  attack,  and  it  may  more  properly  be  regarded  as  an 
expression  of  the  profound  nutritional  perversion  of  fibrous  and 
other  tissues  which  syphilis  produces. 

Etiologically  syphilis  is  met  with  either  as  the  acquired  or  the 
hereditary  form.  In  the  former  case  the  disease  is  implanted  by 
direct  inoculation,  in  the  latter  case  by  inoculation  of  the  foetus 
through  the  placenta. 

It  is  now  generally  thought  that  some  form  of  micro-organism  is 
the  cause  of  syphilis,  and  Lustgarten  has  found  bacilli  similar  in 
appearance  to  those  of  tubercle  in  the  cells  of  gummata. 

Acquired  Syphilis  in  the  Adult 

The  sites  of  inoculation  are  the  mucous  membrane  of  the  genitals, 
lips,  anus,  or  even,  there  is  reason  to  believe,  the  unbroken  skin  of 
the  finger,  as  following  digital  examinations.  Feeding,  and  other 
contaminated  utensils,  have  been  known  to  be  the  means  whereby 
the  virus  has  been  conveyed. 


368  MANUAL  OF  MEDICINE 

Course  and  symptoms. — After  a  period  of  incubation,  lasting 
from  fourteen  to  sixty-three  days,  the  average  being  thirty-five  days, 
the  primary  chancre  appears  at  the  point  of  inoculation  as  a  red  pain- 
less papule,  which  gradually  enlarges  until  it  forms  an  elevated  sore, 
with  steep,  well-defined  margins  and  flattened  top.  The  base  of  the 
sore  is  much  indurated,  the  induration  being  of  a  cartilaginous 
consistence,  the  tissues  around  sharing  in  this.  This  is  the  typical 
hard  or  Hunterian  chancre,  which,  unless  irritated,  never  suppurates. 
Its  surface  is  often  covered  by  a  brown  scab  which  arises  from  a 
clear  serum-like  secretion  oozing  from  the  surface  of  the  sore. 
Many  modifications  of  this  typical  chancre  are  met  with,  and  it  is 
often  difficult  to  be  sure  of  the  identity  of  a  lesion  without  awaiting 
the  time  necessary  for  the  development  of  secondary  syphilitic  symp- 
toms. In  cleanly  persons,  and  if  the  inoculation  is  on  the  glans 
penis,  a  "  coppery  "  desquamating  papule  may  be  the  only  sign  of 
the  implantation  of  disease,  and  the  typical  Hunterian  chancre  does 
not  follow.  It  is  important  to  recognise  such  a  variety  as  this,  as  it 
may  be  readily  overlooked  by  the  patient,  and  even  by  the  medical 
man,  so  that  the  disease  may  be  untreated  in  its  earlier  stages,  when 
it  is  essential  that  thorough  treatment  should  be  carried  out.  It  seems 
also  that  such  chancres  are  sometimes  followed  by  secondary  symp- 
toms of  so  shght  a  character  as  to  pass  unnoticed,  but  it  is  just  in 
these  cases  that  degeneration  of  the  central  nervous  system  and 
of  the  vessels  often  follows  in  middle  Hfe.  In  other  cases  the  in- 
fection is  of  the  mixed  variety,  i.e.  the  virus  of  "soft"  and  of  "hard" 
chancre  are  implanted  at  the  same  time,  and  one  or  more  of  the 
soft  chancres  may  heal,  and  then  undergo  the  characteristic  in- 
duration of  syphilis,  and  a  hard  chancre  ensues.  The  indura- 
tion may  be  like  a  piece  of  parchment  or  a  button  let  into 
the  mucous  membrane  or  skin.  It  lasts  for  a  variable  time,  for 
about  two  to  four  months,  and  then  the  ulcer  heals  and  a  scar  is 
left.  In  women  chancres  on  the  mucous  membrane  of  the  genitals 
are  by  no  means  so  well  marked  nor  so  well  defined  as  in  men. 
The  diagnosis  of  a  typical  hard  chancre  is  not  difficult,  but  the 
identification  of  the  disease  when  the  desquamating  papule,  or 
when  soft  chancres  are  present,  and  when  the  hard  chancre  has  been 
irritated  by  caustics,  so  that  it  suppurates,  is  not  easy.  A  chancre 
and  herpes  of  the  penis  are  sometimes  confused. 

From  the  seat  of  inoculation  the  virus  spreads  to  the  lymphatic 
glands  of  the  groin  and  these  become  enlarged  and  hard.  They 
are  painless,  non-adherent  to  the  skin,  and  do  not  suppurate  unless 
the  chancre  be  irritated  or  be  of  the  mixed  variety,  i.e.  "  hard  "  and 


BERI-BERI  353 


BERI-BERI 

A  specific  peripheral  polyneuritis,  characterised  by  disorders  of 
sensation,  paresis,  changes  in  the  electrical  response  of  the  muscles 
and  nerves,  and  widespread  vasomotor  disturbances  of  such  a  nature 
as  to  cause  either  a  general  anasarca  or  an  atrophic  appearance  of 
the  body.  The  disease  is  one  of  environment,  and  may  become 
endemic  in  locahties  or  abodes.  It  is  usually  attended  by  a  high 
mortality,  death  resulting  from  exhaustion,  paralysis  of  the  heart,  or 
of  the  muscles  concerned  in  respiration. 

Geographical  distribution. — Originally  described  by  Bontius 
in  India,  the  disease  has  in  recent  years  been  scientifically  studied 
in  many  tropical,  sub-tropical,  and  even  temperate  climates,  more 
especially  in  Japan,  in  Brazil,  and  in  the  Dutch  East  Indies.  In 
addition  to  its  occurrence  in  these  several  countries  beri-beri  is  met 
with  in  the  southern  provinces  of  China,  in  Annam,  throughout 
Malaya,  Borneo,  Fiji,  New  Caledonia,  and  even  amongst  natives  of, 
and  the  Chinese  immigrants  in,  Australia.  In  America  it  is  found 
amongst  the  fishermen  of  the  North  Atlantic  sea-board,  in  Havana, 
at  Panama,  in  Brazil,  and  in  the  Sandwich  Islands.  In  Africa  cases 
have  been  met  with  from  the  neighbourhood  of  Lake  Nyassa  and 
the  Congo  (Manson).  Lastly,  attention  has  been  drawn  to  the 
disease  in  several  places  in  Europe,  more  especially  in  Ireland,  where, 
in  the  Richmond  Asylum,  Dublin,  during  1896,  1897,  and  1898,  a 
marked  outbreak  of  the  disease  has  been  described  by  Dr.  Conolly 
Norman. 

Etiology. — The  cause  of  beri-beri  has  not  yet  been  ascertained. 
A  bacterium  was  figured  and  described  by  Pekelharing  and  Winkler 
as  the  result  of  their  investigations  in  Java  and  Sumatra,  but  the 
specific  nature  of  the  organism  has  not  been  confirmed  by  subse- 
quent observers. 

A  diet  deficient  in  nitrogen,  such  as  rice,  especially  when  the 
grain  is  of  inferior  quality  and  deprived  of  its  outer  covering,  is  by 
many  competent  observers  held  to  be  associated  with  outbreaks  of 
beri-beri.  The  chief  reason  for  this  belief  is  that  a  change  to  a 
more  nitrogenous  diet  is  frequently  followed  by  the  disappearance 
of  the  disease.  In  the  Japanese  navy,  where  beri-beri  (kakke)  was 
very  frequent,  a  change  in  diet  of  the  kind  indicated  was  followed 
by  highly  satisfactory  results.     There  are  several  arguments  against 

VOL.  I  2  A 


354  MANUAL  OF  MEDICINE 

rice  being  a  direct  factor  in  the  etiology,  none  being  more  potent 
than  the  late  peculiarly  isolated  outbreak  in  the  lunatic  asylum  in 
DubUn.  By  some  the  disease  has  been  ascribed  to  the  consumption 
of  certain  species  of  fish  imperfectly  cooked. 

Of  other  assigned  causes  there  are  many.  Overcrowding, 
malaria,  climate,  anaemia,  may  furnish  a  favourable  nidus  for  an 
outbreak  of  beri-beri  by  lowering  the  vitality  and  diminishing  the 
bodily  powers  of  resistance,  but  they  cannot  determine  the  onset  of 
a  disease  of  so  specific  a  character.  Beri-beri  is  essentially  the 
disease  of  environment  or  habitation.  It  would  seem  as  though  a 
dwelling  or  ship  became  infected,  and  that  the  disease  clung  to  the 
place.  As  a  consequence  healthy  persons  taking  up  their  residence 
in  quarters  vacated  by  beri-beri  patients  readily  become  infected. 

The  evidence  goes  to  show  that  beri-beri  is  dependent  upon  a 
toxic  influence,  probably  parasitic  in  nature,  having  its  habitat,  in 
all  probability,  outside  the  human  body.  The  disease  is  not  regarded 
as  directly  contagious,  nor  is  the  beri-beric  considered  to  be  personally 
infectious.  The  writer,  however,  found  what  appeared  to  be  direct 
communicability  take  place  in  a  hospital  for  Chinese  in  Hong- 
Kong.  A  number  of  cases  of  beri-beri  had  been  admitted  to  a 
general  ward,  and  after  a  time  beri-beri  developed  in  several  patients 
suffering  from  open  sores  in  the  same  ward,  whilst  it  passed  over 
those  who  showed  no  wounds.  Young  men  are  most  frequently 
the  subjects  of  beri-beri,  but  with  the  exception  of  infants  and  octo- 
genarians it  has  been  known  to  attack  persons  of  any  age  and  of 
either  sex.  The  rich  as  well  as  the  poor  suffer,  but  the  disease  is 
propagated  and  thrives  in  the  overcrowded,  insanitary  native  hovels, 
in  the  barracks  where  native  soldiers  congregate,  in  the  ill -con- 
structed, insanitary,  and  crowded  temporary  dwellings  on  newly- 
opened  plantations.  Beri-beri  is  also  most  frequently  met  with  at 
low  levels,  and  more  especially,  but  by  no  means  exclusively,  along 
the  sea-coast. 

The  Dutch  observers  in  Sumatra  established  the  fact  that 
between  the  period  of  exposure  and  the  development  of  clinical 
signs  and  symptoms  of  the  disease,  or,  in  other  words,  during  the 
incubation  period,  careful  investigation  will  show  that  there  exist 
several  latent  signs.  Of  these  the  chief  are  a  slight  oedema  along 
the  crests  of  the  tibiae,  and  important  variations  in  the  response  of 
the  muscles  and  nerves  to  electrical  stimuli.  The  minimum  period 
of  incubation  of  beri-beri  is  about  five  weeks.  The  maximum  period 
may  extend  over  several  months. 

Symptoms. — The  "  invasion  "  period  of  beri-beri — the  "  initial 


BERI-BERI 


355 


phase  " — presents  the  following  signs  and  symptoms  : — shght  cedema 
along  the  tibial  crests ;  pale  and  swollen-looking  features ;  a  slight 
rise  in  temperature,  which  may  be  very  evanescent,  lasting  only  a 
few  hours,  but  nevertheless  none  the  less  constant ;  palpitation ;  a 
small,  irritable  pulse;  some  apparent  increase  of  cardiac  dulness ; 
violent  cardiac  impulse ;  a  prolonged  first  and  reduplicated  second 
sound  ;  shortness  of  breath  on  exertion  ;  difficulty  in  walking  quickly 
and  going  up  and  down  stairs  owing  to  muscular  stammering ; 
circumscribed  anaesthesia  and  pain  on  pinching  the  muscles  of  the 
lower  extremities. 

When  beri-beri  has  developed  there  will  always  be  found  in  the 
calf  of  the  legs  a  patch  which  is  insensible  to  a  light  touch,  and  to 
both  galvanic  and  faradic  currents.  The  leg  muscles,  and  after- 
wards the  muscles  of  the  thigh,  become  painful  when  pinched,  and 
the  ancesthetic  areas  increase  in  extent.  The  muscles  become 
weaker,  their  quantitative  irritability  is  diminished,  and  very  slight 
resistance  is  sufficient  to  stop  extension  of  the  leg  and  flexion  of  the 
thigh.  The  muscles  of  the  calf,  when  contracted,  bulge  abnormally, 
but  although  painful  to  pressure  there  is  seldom  found  any  idio- 
muscular  contraction,  nor  are  they  usually  irritable  to  percussion. 
When  the  patient  attempts  to  rise  from  his  bed,  or  to  lie  down, 
considerable  awkwardness  is  noticeable,  and  when  he  attempts  to 
walk  the  gait  is  markedly  abnormal.  He  wavers  when  he  tries  to 
stand  with  his  eyes  closed,  nor  can  he  stand  on  tip-toe,  nor  on  one 
foot.  During  walking  the  patient  raises  the  foot  from  the  floor  with 
difficulty,  the  toes  leaving  the  floor  last,  and,  after  lifting  the  foot 
high  and  pushing  it  forwards,  suddenly  drops  it  on  the  floor.  The 
dynamometer  also  shows  that  the  muscular  power  of  the  hands 
and  arms  is  distinctly  lessened.  As  the  disease  progresses  the 
ancesthetic  areas  in  the  legs  may  extend  from  the  knee  along  the 
inside  of  the  Umbs  to  the  heel ;  and  the  thenar  and  hypothenar 
eminences  in  the  hands  become  anaesthetic,  whilst  as  yet  the  parts 
of  the  hand  beyond  are  unaffected.  The  muscular  sense  is  un- 
disturbed, the  patient  localises  well  and  can  imitate  with  one  limb 
passive  movements  made  for  him  with  the  other.  The  condition  of 
the  reflexes  is  characteristic.  The  knee  jerk  completely  disappears, 
either  from  the  onset  of  the  initial  phase  or  after  a  few  days. 
Ankle  clonus  is  absent,  but  the  superficial  abdominal  and  scrotal 
reflexes  are  readily  elicited.  The  muscles,  more  especially  those 
supplied  by  the  external  popliteal  nerve,  exhibit  the  reaction  of 
partial  degeneration.  Irritability  to  the  faradic  current  is  sup- 
pressed, whether  the  current  is  applied  directly  or  indirectly,  and 


3  56  MANUAL  OF  MEDICINE 

there  is  also  diminution  of  direct  and  indirect  irritability  to  the 
galvanic  current.  The  subsequent  symptoms  depend  largely  on 
the  seat  of  the  nerves  attacked. 

The  dilated  heart  may  give  out,  or  this  condition,  combined 
with  a  sudden  effusion  into  the  pericardium,  may  cause  cyanosis, 
dyspnoea,  or  syncope.  The  respiratory  muscles,  on  the  other  hand, 
may  become  paralysed,  causing  sudden  death  by  asphyxia.  Vomit- 
ing is  a  grave  sign,  and  death,  when  it  occurs,  is  usually  sudden.  In 
favourable  cases  the  oedema,  if  it  exists,  disappears,  the  paralytic 
signs  are  first  stayed  in  their  advance  and  then  abate  in  their 
intensity.  Power  returns  to  the  hands  and  legs,  the  irritabihty  of 
the  heart  lessens,  dyspncea  disappears,  and  after  three  months  or  so 
the  patient  is  usually  able  to  get  about,  or  even  follow  his  employ- 
ment. Occasionally  it  happens  that  paresis  remains  for  an  indefinite 
period.  During  the  development  of  these  paralytic  signs  and 
symptoms  the  general  health  of  the  patient  is  wonderfully  good. 
The  digestive  organs  present  nothing  amiss,  and  the  urine  seldom 
betrays  any  signs  of  renal  disturbance. 

Varieties. — The  three  most  pronounced  types  of  beri-beri  are 
the  oedematous,  wet,  moist,  dropsical;  the  atrophic,  dry;  and  the 
mixed.  In  addition  to  these  names,  however,  we  are  familiar  with 
such  terms  as  "acute"  and  "chronic"  beri-beri,  "foudroyante,"  etc. 
It  is  doubtful  whether  any  one  of  these  is  worthy  of  the  name  of  a 
variety,  as  it  is  possible  the  one  is  but  the  precursor  or  sequel  of 
another,  a  mere  predominant  symptom  being  seized  upon  to 
constitute  the  basis  of  differentiation. 

1.  The  xde7!iatous,  dropsical,  '■'■wet''''  or  '■'■  moist ''"'  form  of  beri- 
beri is  characterised  by  a  fairly  general  cedema.  The  anasarca 
closely  resembles  that  met  with  in  a  case  of  acute  Bright's  disease, 
but  the  urine,  although  presenting  occasionally  a  slight  albuminous 
cloud  on  boiling,  shows  none  of  the  characteristic  features  con- 
sequent on  acute  nephritis.  The  oedema  is  at  times  partial,  often 
missing  the  scrotum,  and  at  times  changing  its  site.  The  serous 
cavities  may  be  the  seat  of  a  large  amount  of  effusion,  the  peri- 
cardial cavity  being  especially  liable  to  effusion  ;  but  the  pleural 
cavities  may  be  filled  to  such  an  extent  that  breathing  is  greatly 
hampered  and  the  lung  space  so  dimmished  that  asphyxia  super- 
venes. 

2.  The  atrophic,  "dry,"  or  purely  paraplegic  variety  of  beri-beri  is, 
as  the  names  imply,  associated  with  shrinking  of  the  tissues  of  the 
body.  The  muscles  are  flabby  and  the  fat  of  the  body  disappears. 
The  patient,  as  regards  his  alimentary  and  renal  condition,   may 


BERI-BERI  357 

be  pronounced  healthy,  and  it  is  to  a  paralysis  of  the  laryngeal  or 
respiratory  muscles  that  he  usually  succumbs. 

3 .  Atrophic  and  (jedetnatous — ' '  mixed ' ' — beri-beri.  — When  atrophic 
symptoms  are  obscured  by  serous  effusion  into  the  muscular 
and  the  connective  tissues,  and  when,  also,  the  serous  cavities  are 
the  seat  of  a  similar  effusion,  the  clinician,  pledged  to  the  cognisance 
of  a  "  wet  "  and  a  "  dry  "  variety  of  beri-beri,  will  find  great  difficulty 
in  referring  the  disease  to  its  particular  variety.  Hence  the  adoption 
of  the  term  "  mixed,"  in  which  the  signs  and  symptoms  of  the  "  wet  " 
and  "  dry  "  varieties  are  combined. 

In  all  these  divergencies,  however,  one  symptom  remams  con- 
stant, viz.  the  electrical  modifications  of  the  nerves  and  muscles. 
It  would  be  well  to  dispense  with  these  distinctions,  except  in  so  far 
as  they  indicate  stages  in  the  disease,  because  oedema  is  only  a 
secondary  phenomenon,  and  if  the  mixed  form  is  taken  as  the  type, 
the  dropsical  and  dry  forms  are  but  a  quantitative  modification 
of  it. 

The  motor  disorders. — The  most  constantly  paralysed  muscles  are 
the  groups  supplied  by  the  external  popliteal  nerves,  viz.  the 
peronei,  and  the  extensors  of  the  toes ;  the  next  most  frequently 
affected  muscles  are  the  flexors  of  the  toes.  The  extensors  of  the 
knee  and  the  gluteal  muscles  are  also  liable  to  be  involved  in  the 
paresis,  whilst  the  adductors  and  the  knee  flexors  escape.  In  the 
upper  extremities  the  extensors  of  the  hand  and  fingers,  the  supinator 
longus,  the  triceps,  the  flexors  of  the  hand  and  fingers  are,  in  the 
order  given,  the  muscles  liable  to  attack.  In  addition  to  these  the 
abdominal  muscles,  the  diaphragm,  and  the  intercostal  muscles 
suffer.  Even  the  muscles  supplied  by  the  cranial  nerves  may 
become  involved  ;  the  muscles  of  expression  and  the  muscles  of 
the  eyeball  having  been  known  to  become  paralysed.  The  laryngeal 
muscles  are  also  frequently  involved,  with  the  result  that  sudden 
death  ensues  from  asphyxia. 

Disorders  of  sensory  nerves. — The  sense  of  touch  is  first  lost  on 
the  inner  aspect  of  the  calf  of  the  leg,  then  on  the  dorsum  of  the 
foot,  and  finally  sensation  may  be  lost  everywhere  below  the  knee. 
In  the  upper  extremities  sensation  disappears  first  on  the  anterior 
aspect  of  the  wrist,  then  over  the  thenar  and  hypothenar  eminences, 
and  finally  over  other  parts  of  the  hand ;  the  ends  of  the  fingers 
being  the  last  places  from  which  it  vanishes.  Anaesthesia  may  over- 
take the  whole  of  the  upper  limb  as  far  as  the  shoulders.  Auccsthetic 
areas  may  also  be  met  with  over  the  anterior  aspect  of  the  trunk, 
reaching  as  low  as  the  umbilicus. 


358  MANUAL   OF   MEDICINE 

Heart  affections. — The  heart  is  early  affected  in  beri-beri.  Not 
only  are  there  marked  subjective  symptoms,  but  there  is  a  pro- 
nounced enlargement  of  the  cardiac  area,  especially  towards  the 
right,  and  pathological  evidence  shows  that  there  is  hypertrophy 
accompanied  by  dilatation  of  the  right  ventricle.  The  state  of 
the  ventricle  explains  the  dropsical  effusion  into  the  tissues  and  the 
serous  cavities  and  the  other  effects  of  venous  obstruction. 

Post-mortem  appearances. — According  to  the  type  of  beri- 
beri which  has  proved  fatal,  so  do  the  post-mortem  evidences  var}-. 
In  the  "  wet  "  variety  serous  effusions  may  be  found  in  the  sub- 
cutaneous and  intermuscular  tissues  and  in  the  serous  cavities  of  the 
body  ;  in  the  "  dry  "  variety,  on  the  other  hand,  the  muscles  when 
cut  into  reveal  the  yellowish-brown  colour  characteristic  of  atrophy. 
It  must  be  remembered,  however,  that  oedema  to  some  extent  has 
always  existed  at  some  period  of  the  disease,  and  pericardial 
effusion  in  particular  is  one  of  the  most  constant  features  of  beri- 
beri. It  is  in  the  heart  itself,  however,  that  pathological  change  is 
to  be  sought  for.  Hypertrophy  of  the  right  ventricle  is  always 
present,  accompanied  by  a  dilatation  varj-ing  from,  it  may  be  a  small, 
to  an  enormous  extent.  The  heart  muscle  is  often  pale,  but 
microscopic  examination  shows  that  this  is  not  usually  due  to 
fatty  degeneration.  Of  the  other  organs  the  lungs  may  be  cedema- 
tous,  the  liver  congested,  the  spleen  increased  in  bulk  and  weight, 
and  the  blood  in  the  large  veins  in  a  fluid  state.  The  examination 
of  the  ner^'ous  system  shows  that,  in  the  nerves  generally,  a  state  of 
peripheral  neuritis  and  ner\'e  degeneration  exists,  and  that  the 
lesion  diminishes  in  intensity  as  the  centre  is  approached.  The 
anterior  roots  of  the  spinal  nerves  show  no  pathological  change, 
but  in  the  posterior  roots,  more  especially  in  the  part  between  the 
ganglion  and  the  nerve  trunk,  atrophied  fibres  are  met  with.  In 
the  central  nervous  system  the  most  constant  change  is  an  alteration 
(it  may  be  an  atrophy)  in  the  large  cells  occupying  the  anterior 
cornua  of  the  spinal  cord. 

Prognosis. — During  an  attack  of  beri-beri  it  is  well-nigh  im- 
possible to  venture  on  a  prognosis  ;  for  cases  of  seeming  mildness 
prove  fatal,  whilst  cases  of  apparently  a  severe  type  recover.  In 
general  about  20  per  cent  of  those  attacked  die;  but  the  numbers 
vary,  it  may  be  as  much  as  i  o  or  even  1 5  per  cent  either  way.  Un- 
favourable signs  are :  cardiac  and  vascular  changes,  such  as  a  quick 
and  feeble  pulse,  epigastric  pulsation,  throbbing  of  the  blood  vessels 
in  the  neck  and  increase  in  the  cardiac  area ;  extensive  serous 
effusions  into  the  peritoneal,  pleural  or  pericardial  ca^dties ;  failure 


BERI-BERI  359 

in  power  of  the  respiratory  muscles ;  marked  diminution  in  the 
quantity  of  urine  passed ;  and  vomiting.  The  last  -  mentioned 
feature  supervening,  as  it  sometimes  does  during  the  course  of  an 
acute  attack  of  beri-beri,  is  a  very  unfavourable  sign. 

Diagnosis. — Beri-beri  has  to  be  diagnosed  from  peripheral 
neuritis,  due  to  alcohol  or  to  malaria,  from  locomotor  ataxy,  and  from 
epidemic  dropsy.  In  epidemic  forms  of  the  disease  the  diagnosis 
is  readily  enough  arrived  at,  but  when  sporadic  cases,  or  when  even 
limited '  outbreaks  occur  in  what  are  regarded  as  non-beri-beric 
countries,  as  in  Ireland,  the  recognition  of  the  disease  is  attended  by 
obvious  difficulties.  Reliance  must  be  placed  upon  the  presence  of 
oedema,  limited,  it  may  be,  to  the  front  of  the  shins ;  upon  the 
absence  of  knee  jerk ;  upon  the  tumbling  action  of  the  heart ;  pain 
on  pinching  the  limb  muscles  and  patches  of  anaesthesia  on  the 
legs  and  perhaps  the  arms.  If  electrical  testing  is  available  the 
diagnosis  is  greatly  facilitated. 

Treatment — Prophylaxis. — Seeing  that  beri-beri  is  a  disease  of 
environment  it  is  necessary  to  correct  or  alter  the  immediate 
surroundings  of  those  exposed  to  the  disease.  Disinfecting  the 
abode,  the  furniture,  and  the  clothing  of  beri-berics  serves  to  check 
the  numbers  of  those  attacked  \  but  it  is  only  by  evacuating  the 
premises,  and  it  may  be  leaving  the  locality  where  beri-beri  is 
endemic,  that  an  outbreak,  say,  amongst  troops  in  barracks,  coolies 
in  coolie  quarters,  and  prisoners  in  a  jail,  may  be  stamped  out.  In 
the  case  of  the  individual  it  is  only  by  removal  to  an  untainted 
locality  that  a  cure  can  be  confidently  hoped  for. 

Rest  in  bed  ought  to  be  insisted  upon  and  sudden  movement  or 
exertion  forbidden.  The  diet  must  be  Uberal  in  the  item  of 
nitrogenous  elements,  and  if  rice  has  been  the  staple  food  heretofore 
it  should  be  supplanted  by  bread,  meat,  milk,  and  fresh  vegetables. 
When  it  is  impossible  to  immediately  quit  the  abode,  as  on  board 
ship,  those  afflicted  with  beri-beri  should  be  granted  the  best  sleeping 
accommodation  possible,  and  during  the  day  should  be  brought  out 
into  the  open  air. 

The  state  of  the  heart  and  of  the  circulatory  organs  generally  calls 
for  medicinal  treatment.  Cardiac  stimulants,  such  as  digitalis,  may 
be  administered  with  good  effect ;  nitroglycerine  in  the  form  of  the 
liquor  trinitrini  (i  min.),  or  tabellae  nitroglycerini  B.P.  (i  tablet) 
should  be  at  hand  for  emergencies  of  cardiac  failure.  Amyl  nitrite 
may  be  inhaled  from  a  crushed  capsule  with  the  same  intention. 
The  functional  condition  of  the  heart  in  beri-beri  is  so  little  under- 
stood that  it  is  difficult  to  justify,  far  less  to  explain  the  beneficial 


360  MANUAL  OF  MEDICINE 

action  of  these  drugs,  except  it  be  that  by  the  administration  tem- 
porary reUef  is  afforded  to  the  enlarged  right  ventricle,  by  diminishing 
the  resistance  of  the  blood  vessels  to  the  onward  passage  of  the 
blood. 

Aspiration  of  first  one,  and  (if  necessar}')  later  the  other  pleural 
cavity  affords  relief  in  dyspnoea,  and  the  writer  found  benefit  by 
venesection  in  one  case  of  threatened  asphyxia  and  by  aspiration  of 
the  pericardial  effusion  in  another. 

When  the  patient  is  convalescing  strjxhnine  is  the  best  medicinal 
tonic ;  but  massage,  electrical  stimulation  and  general  tonic  treat- 
ment favours  recover}\  It  was  at  one  time  believed  that  beri-beri 
always  relapsed,  and  that  in  about  twelve  months  a  recrudescence  was 
to  be  looked  for.  No  doubt  this  is  the  case  when  the  patient 
returns  to  an  infected  environment,  but  by  residence  in  a  healthy 
locality  such  a  relapse  may  be  almost  certainly  avoided. 

James  Caxtlie. 


EPIDEMIC   DROPSY 

An  epidemic  disease  of  variable  mortality  and  lasting  from  three 
to  six  weeks ;  characterised  by  oedema  of  the  lower  extremities  or 
of  the  entire  body,  accompanied  by  pyrexia,  by  gastric  and  intestinal 
irritation,  by  aching  in  the  limbs  and  trunk,  and  frequently  by  a 
cutaneous  rash  of  a  rubeolar  appearance. 

Geographical  distribution. — Since  Dr.  Kenneth  M'Leod 
first  described  the  disease  in  Calcutta  in  1877,  several  observers 
have  recorded  outbreaks  of  the  disease.  In  Assam,  in  Lower 
Bengal,  and  in  Mauritius,  well-defined  occurrences  have  taken 
place,  and.  in  all  probability,  outbreaks  of  this  particular  malady 
have  developed  at  several  places  on  the  littoral  of  the  Indian 
Ocean. 

Etiology. — Epidemic  dropsy  appears  to  be  communicable 
from  one  member  of  the  community  to  another,  and  is  mainly  con- 
fined to  the  adults  of  both  sexes  of  a  family.  It  occurred  in 
Calcutta  during  the  cold  weather,  disappeared  completely  during 
the  hot  season,  and  for  three  successive  winters,  1887  to  1890, 
recurred  persistently ;  since  then  the  disease  does  not  seem  to 
have  re-appeared.  No  European  is  known  to  have  contracted  the 
disease. 


EPIDEMIC  DROPSY  361 

No  bacteriological  investigations  have  been  as  yet  communicated 
concerning  the  causation  of  epidemic  dropsy. 

Symptoms. — Initial  symptoms  vary.  In  some  instances  the 
disease  is  ushered  in  by  the  dropsical  effusion  ;  in  others,  fever  first 
attracts  attention  ;  or  again  general  malaise  or  intestinal  flux  precede 
all  other  manifestations. 

The  oedema  appears  in  the  feet  and  ankles  and  may  extend 
beyond  the  lower  extremities  to  the  whole  body,  sometimes  lasting 
for  a  considerable  period.  Pleural  and  pericardial  effusions  have 
sometimes  been  noticed.  Fever  may  usher  in  the  symptoms,  may 
accompany  the  dropsy  or  appear  only  during  its  subsidence.  It  is 
seldom  the  thermometer  registers  higher  than  102°.  Vomiting  is 
seldom  distressing  ;  diarrhoea  or  even  dysentery  of  a  mild  type  occa- 
sionally occurs.  In  addition  to  itching  and  burning  of  the  skin,  a 
general  exanthematous  rasli,  of  a  rubeolar  character,  is  a  common, 
but  by  no  means  a  constant,  accompaniment.  The  general  signs 
and  symptoms  include  a  weakened  pulse,  breathlessness,  and  marked 
anaemia  and  prostration.  Nocturnal  pains  in  the  limbs  have  been 
frequently  observed. 

Occasional  signs  and  symptoms  of  pneumonia,  oedema  of  the 
lungs,  cardiac  dilatation,  scurvy,  and  albuminous  urine  have  all  been 
recorded  as  complications  of  the  disease. 

Diagnosis. — The  only  disease  likely  to  be  confused  with  epi- 
demic dropsy  is  beri-beri.  In  fact  many  observers  positively  assert 
their  identity ;  whilst  on  the  other  hand  it  is  possible,  nay  probable, 
that  many  cases  at  present  classed  as  beri-beri  will  prove  to  be  of  the 
nature  of  epidemic  dropsy.  The  one  characteristic  feature  of  beri- 
beri which  serves  definitely  to  stamp  its  specific  nature  is  the  nervous 
and  paralytic  affections,  and  these  are  absent  in  epidemic  dropsy. 
Moreover,  beri-beri  is  more  chronic  and  never  complicated  by  a 
cutaneous  eruption,  nor  is  fever  a  prominent  feature. 

Mortality. — In  the  Calcutta  epidemics  a  death-rate  of  from 
twenty  to  forty  per  cent  of  those  attacked  occurred.  On  the  other 
hand,  in  the  Assam  outbreak,  no  fatal  cases  were  known. 

Treatment. — Such  remedial  treatment  as  a  weakened  circula- 
tion demands,  and  as  is  appropriate  in  urgent  cases  of  dyspnoea 
or  apncea  is  called  for  in  the  treatment  of  epidemic  dropsy. 

Southey's  trocars  are  indicated  as  a  means  of  relieving  the 
dropsical  effusion,  and  even  aspiration  of  the  pleura  or  pericardium 
may  be  necessary.  During  convalescence  anaemia  is  the  most 
prominent  condition  which  requires  treatment. 

James  Cantlie, 


362  MANUAL  OF  MEDICINE 


ORIENTAL  SORE 
Syn.  Delhi  Boil  ;  Bagdad  Sore  ;  Biskra  Button  ;  Aleppo  Evil 

A  specific  inflammatory  affection  of  the  deeper  layers  of  the 
skin,  which,  commencing  as  a  papule,  soon  crusts  over,  and  spread- 
ing by  phagedasna,  develops  an  ulcer  of  an  indolent  character. 
The  healing  is  protracted,  and  a  permanent  scar,  a  "  date  "  mark, 
remains  to  indicate  the  seat  of  the  affection. 

Geographical  distribution. — The  various  synonyms  indicate 
the  principal  places  in  which  this  peculiar  affection  is  met  with.  In 
Europe,  Greece  and  Crete  seem  to  be  the  only  countries  in  which 
the  disease  has  been  noted.  In  Africa  it  occurs  in  Morocco,  Egypt, 
and  certain  parts  of  the  Sahara.  In  Asia:  Bagdad  in  Mesopotamia, 
Aleppo  in  Syria,  Delhi  and  Mooltan  in  India,  are  the  chief  seats 
of  the  disease.  But  Arabia,  Persia,  and  Turkestan  are  known  also 
to  harbour  the  malady.  Some  ten  years  ago  persons  residing  in  the 
town  of  Bahia,  Brazil,  were  declared  to  be  affected  with  true 
"Oriental  Sore." 

What  the  specific  infective  matter  may  be  is  unknown.  Objects 
that' appear  to  be  minute  parasites  in  the  "  boil "  have  been  described 
by  Dr.  Smith  as  the  ova  of  Distoma,  by  Dr.  V.  Carter  as  the 
spheroids  and  mycelium  of  a  special  parasite,  and  by  Dr.  Cunning- 
ham as  zoocysts  or  sporocysts  which  are  also  met  with  in  the  water 
in  some  of  the  districts  where  Oriental  sore  is  endemic.  Biting 
insects  are  in  all  probability  the  carriers  of  the  infectious  matter,  as 
it  is  the  exposed  parts  of  the  body  that  are  almost  solely  attacked. 

Etiology. — It  would  seem  as  though  a  special  state  of  climate  and 
constitution  were  necessary  for  the  development  of  the  disease,  as  it 
occurs  in  countries  possessing  for  the  most  part  a  dry,  even  arid, 
climate,  and  it  appears  towards  the  end  of  the  hot  season,  when  the 
vigour  of  those  attacked  is  probably  at  its  lowest.  Insanitary  surround- 
ings favour  the  development  of  Oriental  sore.  All  nationalities,  both 
sexes  and  all  ages,  are  liable  to  attack,  and  the  disease  seems  to 
occur  in  special  prev^alence,  not  only  at  certain  seasons,  but  also 
during  certain  years. 

One  attack  as  a  rule  confers  a  permanent  immunity. 

Coramunicability. — The  disease  is  not  confined  to  human 
beings.      Dogs  and   horses  are  stated  by  Fayrer  to  suffer  from  a 


ORIENTAL  SORE  363 

disease  in  India  closely  resembling  Oriental  sore.  Both  man  and 
the  lower  animals  can  be  inoculated  by  discharge  from  the  surface 
of  ulcers.  Attempts  at  inoculations  from  cultures  of  certain  micro- 
cocci obtained  from  the  centre  of  the  papules  have  hitherto  failed. 

Sjmaptoms. — On  some  exposed  part,  or  parts,  of  the  body, 
usually  the  face,  neck,  or  extremities,  the  attention  of  the  patient  is 
drawn  to  a  small  itching  papule,  or  to  a  number  of  similar  pimples  on 
different  parts  of  the  body.  When  looked  at  carefully  the  papule 
appears  pink  in  colour ;  it  is  frequently  situated  around  a  hair 
follicle,  and  the  epidermis  over  it  is  seen  to  be  dry  and  loose. 
Gradually  the  subcutaneous  tissues  around  become  infiltrated  and 
feel  boggy  to  the  touch ;  the  intense  itching  alternates  with  occa- 
sional stinging  pains ;  and  a  slight  oozing  from  the  surface  and 
moistening  of  the  skin  causes  the  epidermal  cells  to  cake,  and 
finally  to  crust.  Underneath  the  crust  an  ulcerating  surface 
develops,  at  first  quite  superficially,  but  gradually  the  ulceration 
extends  deeper  and  wider,  presenting  a  rather  sharply  cut  and 
indurated  edge.  The  crusts  fall  and  re-form  from  the  thin  ichorous 
material  which  exudes.  Around  the  primary  papule  others  form, 
and,  as  these  coalesce,  they  add  to  the  extent  and  intractability 
of  the  sore.  An  individual  sore  is  usually  about  one  inch  in 
diameter,  and  there  may  be  several  on  different  parts  of  the  body. 
It  is  believed  also  that  any  ordinary  boil  or  wound  may  take  on  the 
characters  peculiar  to  Oriental  sore.  After  many  weeks,  or  more  likely 
months,  the  wound  shows  signs  of  healing.  Slow  in  its  development, 
however,  the  "  sore  "  is  still  slower  in  its  disappearance,  and  it  leaves 
behind  the  peculiar  "  date  "  scar,  indelibly  impressed.  The  cheek 
and  nose  are  favourite  sites  of  the  disease,  and  a  large  "  date  "  mark 
on  either  of  these  may  be  followed  by  permanent  unsightliness. 

Prognosis. — There  is  but  little  danger  to  life  from  Oriental 
sore.  Were  the  wound  to  be  attacked  by  erysipelas,  or  become 
markedly  phagedasnic,  alarming  symptoms  might  ensue. 

Treatment. — Destruction  by  caustics  or  cautery  of  the  primary 
seat  of  infection  has  been  frequently  attempted,  but  the  results  are 
not  encouraging ;  and  in  the  absence  of  any  known  specific  appli- 
cation, it  is  wiser  to  pursue  an  expectant  treatment,  viz.  attending 
to  the  general  health,  seeing  to  the  sanitation  of  the  house  and 
environment,  applying  soothing  antiseptic  remedies  to  the  sore 
whilst  it  is  indurated  and  irritable,  and  promoting  healing  by 
cleansing  the  wound  and  protecting  its  surface. 

James  Cantlie, 


;64  MANUAL  OF  MEDICINE 


VERRUGA  PERUANA 


A  specific,  general,  infective,  inoculable  disease,  characterised  by 
constitutional  symptoms  and  a  special  granulomatous  eruption.  It 
seems  to  be  quite  distinct  from  framboesia. 

The  disease  is  peculiar  to  certain  defiles  penetrating  the  tropical 
Andean  mountainous  districts  of  the  departments  of  Ancache  and 
Lima,  which  are  watered  by  rivers  overflowing  each  January  and 
June.  There  are  no  limitations  as  to  age,  sex,  or  race.  Domestic 
animals,  such  as  dogs,  pigs,  fowls,  turkeys,  horses,  mules,  llamas, 
cows,  and  asses  contract  the  disease,  which  assumes  remarkable 
proportions  in  the  solipeds. 

Eight  to  forty  days  are  generally  allowed  to  be  the  incubation 
period  ;  some  observers  give  even  a  longer  range. 

The  invasion  symptoms  may  be  of  very  different  degrees  of 
severity.  The  malady  may  be  so  intensely  virulent  that  the  patient 
succumbs  before  the  eruption  appears.  Usually  there  is  an  in- 
sidious onset  with  general  malaise,  which  gradually  becomes  inten- 
sified. Pain  and  fever  are  prominent.  Rheumatoid  pains,  with 
nocturnal  exacerbations,  shift  from  joint  to  joint,  and  are  often 
terribly  severe.  Muscular  pains,  also,  may  produce  rigidity  and 
contractions.  A  great  variety  of  febrile  types  are  observed,  of  which 
the  acute  arthritic  and  low  typhoid  may  be  especially  noted.  The 
fever  may  be  intermittent,  and  is  generally  hectic ;  the  intensity 
corresponds  with  the  virulence  of  the  infection.  A  marked  anaemia 
sets  in,  with  profound  prostration,  and  these  states  are  apt  to  be 
increased  by  the  subsequent  ulceration  and  bleeding  of  the  eruption. 
Hsemic  murmurs  may  develop,  serous  effusions  are  frequent,  and 
the  spleen,  and  sometimes  the  liver,  enlarges.  The  eruption  appears 
after  a  period  of  twenty  days,  or  only  after  six  or  eight  months,  or 
even  one  year,  it  is  said,  and  when  it  evolves  the  general  symptoms 
tend  to  abate.  Its  duration  may  be  put  at  about  two  to  eight  months, 
but  varies  widely  according  to  the  number  of  outbursts,  and  the 
quantity  and  volume  of  the  elements  and  attending  complications. 
It  appears  usually  in  the  skin  of  the  extremities  and  face,  and  spreads 
thence  to  more  or  less  of  the  rest  of  the  body,  and  to  the  mucous 
membranes,  and  even  the  splanchnic  organs  and  serous  membrane. 
The  distribution  is,  however,  most  variable.  The  eruptive  elements 
may  be  small  and  superficial,  or  develop  more  deeply  in  the  cutis 


FRAMBCESIA  365 

and  subcutaneous  tissue,  and  then  attain  the  size  of  an  orange,  or 
more,  and  give  rise  to  grave  cachexia  by  their  sloughing  and  bleeding. 
The  smaller  type  begins  as  a  tiny  red  spot,  which  develops  into  an 
itching,  shining  papule,  and  finally  into  a  very  vascular,  red  "  wart " 
(whence  the  name  verruga),  which  may  become  pedunculated.  The 
eruptions  gradually  die  away  with  exfoliation  or  bleeding,  or  ulcera- 
tion and  crusting.  Histologically  the  granulomata  are  said  to  bear  a 
striking  resemblance  to  sarcomata,  and  to  be  specially  characterised 
by  a  remarkable  vascularity.  According  to  Yzquierdo,  they  are 
caused  by  a  specific  bacillus,  which  is  found  between  the  cells,  and 
also  thrombosing  the  vessels. 

The  diagnosis,  in  the  pre-eruptive  stages  from  malaria,  rheu- 
matic and  typhoid  fevers,  is  often  very  difficult.  Verruga  is  a  very 
serious  and  dangerous  affection. 

There  is  no  specific  treatment  known  to  be  effective.  The 
sufferer  should  be  removed  at  once  to  as  healthy  a  locality  as  possible 
at  the  sea  level. 

T.  CoLCOTT  Fox. 


FRAMBCESIA 


A  highly  contagious,  but  not  hereditary,  specific,  general, 
chronic,  infective  disorder,  characterised  by  a  cutaneous  granulo- 
matous eruption  of  special  aspect,  resembling  a  raspberry,  whence 
the  name  is  derived  through  the  French  "  framboise."  It  is  endemic 
in  some  of  the  West  Indian  Islands  ("  yaws  "),  especially  Dominica  ; 
in  parts  of  Brazil  and  the  Spanish  South  American  colonies 
("  bubas  ")  and  Guiana  ;  in  Fiji  ("  koko  "),  Loyalty,  New  Caledonia, 
and  other  Melanesian  Islands ;  in  Ceylon  ("  paranghi "),  along  the 
Coromandel  Coast,  Assam,  and  the  East  Indies  ;  in  the  Moluccas, 
the  East  Coast  of  Africa,  along  the  Mozambique  Channel,  and 
on  the  West  Coast  about  Sierra  Leone.  One  attack  renders  the 
subject  immune  for  the  most  part.  It  is  not  syphilis  altered  by 
race,  climate,  and  locality,  for  both  diseases  breed  true  in  the 
same  community ;  syphilis  can  be  inoculated  and  run  a  typical 
course  in  a  yaws  subject,  and  healthy  children  are  born  of  women 
actually,  or  recently,  suffering  from  yaws.  Moreover,  the  incubation 
stages  are  different,  and  many  of  the  secondary  symptoms  character- 
istic of  syphilis,  such  as  iritis,  sore  throat,  and  usually  the  adeno- 


366  MANUAL  OF  MEDICINE 

pathy,  are   absent.     Tertiary  symptoms   do   not   follow,  it   is   said, 
though  ulceration  is  not  unfrequent. 

Inoculation  occurs  through  any  of  the  breaches  of  surface,  so 
frequent  in  unclothed  people  living  under  unhygienic,  crowded, 
miserable  conditions. 

After  an  incubation  period,  variously  stated  from  two  to  ten 
weeks,  or  a  somewhat  shorter  average  time  (twelve  to  twenty  days) 
in  experimental  inoculations,  an  initial  papule  appears  at  the  seat 
of  inoculation  in  a  considerable  proportion  of  cases,  though  not 
invariably,  and  develops  into  a  moist,  yellow,  fungating  granuloma, 
similar  to  those  of  the  generalised  eruption,  and  sometimes  persist- 
ing for  a  long  period  as  the  "mother-yaw."  Simultaneously  with 
the  initial  papule,  or  shortly  after,  but  usually  within  ten  days,  a 
granulomatous,  more  or  less  generalised,  eruption  appears  in 
successive  crops,  and  may  last  as  a  whole  from  three  months  to  four 
years,  averaging  about  two  years.  The  eruption  evolves  as  itching 
papules,  the  size  of  pin-heads,  which  may  abort  in  the  early  stages 
with  the  separation  of  corresponding  scales.  Some  authors  draw 
special  attention  to  the  occurrence  of  such  furfuraceous  desquama- 
tion in  the  earlier  stages  of  the  effection  or  at  later  periods.  As  a 
rule  the  enlarging  papule  bursts  through  the  epidermis  and  discloses 
a  central,  yellowish,  softened  point  which  may  simulate  a  pustule. 
Finally,  an  abruptly -raised,  painless  excrescence  is  formed  like 
"  proud  flesh,"  or  somewhat  resembling  mucous  tubercles  or  condy- 
lomata, or,  in  certain  rarer  dry  states,  warts.  These  efflorescences  may 
reach  the  size  of  a  small  pea,  or  even  a  walnut,  and  may  form 
larger  patches  by  confluence,  or  become  annulate.  They  tend  to 
be  covered  with  a  thin  scab,  and  on  disappearance  after  some  weeks 
leave  a  stain  lasting  a  few  or  many  months.  In  many  cases  succes- 
sive crops  continue  to  appear.  The  eruption  may  be  generalised 
and  copious,  or  scanty  and  localised.  The  lips  and  nostrils  may  be 
implicated,  but  otherwise  the  mucous  membranes  appear  to  escape, 
as  do  the  viscera.  In  the  conditions  under  which  frambcesia  occurs 
it  is  not  surprising  that  secondary  ulcerations  should  result  in  many 
cases.  The  causal  micro-organism  has  not  yet  been  definitely 
established. 

Constitutional  symptoms,  such  as  fever,  are  absent,  slight,  or  rarely 
severe,  and,  as  a  rule,  the  subjects  continue  their  usual  avocations. 

Treatment. — Isolation  is  necessary  to  prevent  the  spread  of 
the  disease.  In  ordinary  cases,  where  the  general  health  is  good, 
the  disease  runs  its  natural  mild  course  under  proper  feeding  and 
hygiene,  and  the  prognosis  is  most  favourable.     Mercury  and  iodide 


SYPHILIS  367 

of  potassium  have  been  much  used,  and  the  reports  as  to  their  action 
are  most  conflicting.  The  local  application  twice  daily  of  chromic 
acid,  or  a  mixture  of  picric  and  carbolic  acid  to  dry  up  the  granulo- 
mata  is  recommended ;  and  for  some  of  the  later  and  more  per- 
sistent lesions  nitrate  of  silver  and  sulphate  of  copper  are  useful. 

T.  CoLCOTT  Fox. 


SYPHILIS 


Syphilis  is  a  specific  contagious  disease,  communicable  by  direct 
inoculation.  Its  course  is  characterised  by  a  primary  lesion  (chancre), 
by  early  constitutional  (secondary)  symptoms,  and  by  late  constitu- 
tional (tertiary)  symptoms. 

Frequently  a  final  stage  is  to  be  observed,  a  post-syphilitic  fibrosis, 
especially  well  marked  in  the  blood  vessels,  nervous  tissues,  and  bones, 
in  which  there  is  an  overgrowth  of  the  connective-tissue  elements  of 
those  structures,  the  fibrous  overgrowth  being  such  that  although  it 
appears  to  be  the  result  of  the  continued  action  of  the  syphilitic 
virus,  yet  it  refuses  to  yield  to  the  usual  anti-syphilitic  remedies. 
For  this  reason  some  authorities  do  not  regard  it  as  an  integral  part 
of  the  syphilitic  attack,  and  it  may  more  properly  be  regarded  as  an 
expression  of  the  profound  nutritional  perversion  of  fibrous  and 
other  tissues  which  syphilis  produces. 

Etiologically  syphilis  is  met  with  either  as  the  acquired  or  the 
hereditary  form.  In  the  former  case  the  disease  is  implanted  by 
direct  inoculation,  in  the  latter  case  by  inoculation  of  the  foetus 
through  the  placenta. 

It  is  now  generally  thought  that  some  form  of  micro-organism  is 
the  cause  of  syphilis,  and  Lustgarten  has  found  bacilli  similar  in 
appearance  to  those  of  tubercle  in  the  cells  of  gummata. 

Acquired  Syphilis  in  the  Adult 

The  sites  of  inoculation  are  the  mucous  membrane  of  the  genitals, 
lips,  anus,  or  even,  there  is  reason  to  believe,  the  unbroken  skin  of 
the  finger,  as  following  digital  examinations.  Feeding,  and  other 
contaminated  utensils,  have  been  known  to  be  the  means  whereby 
the  virus  has  been  conveyed. 


368  MANUAL  OF  MEDICINE 

Course  and  symptoms. — After  a  period  of  incubation,  lasting 
from  fourteen  to  sixty-three  days,  the  average  being  thirty-five  days, 
the  primary  chancre  appears  at  the  point  of  inoculation  as  a  red  pain- 
less papule,  which  gradually  enlarges  until  it  forms  an  elevated  sore, 
with  steep,  well-defined  margins  and  flattened  top.  The  base  of  the 
sore  is  much  indurated,  the  induration  being  of  a  cartilaginous 
consistence,  the  'issues  around  sharing  in  this.  This  is  the  typical 
hard  or  Hunterian  chancre,  which,  unless  irritated,  never  suppurates. 
Its  surface  is  often  covered  by  a  brown  scab  which  arises  from  a 
clear  serum-like  secretion  oozing  from  the  surface  of  the  sore. 
Many  modifications  of  this  typical  chancre  are  met  with,  and  it  is 
often  difficult  to  be  sure  of  the  identity  of  a  lesion  without  awaiting 
the  time  necessary  for  the  development  of  secondary  .syphilitic  symp- 
toms. In  cleanly  persons,  and  if  the  inoculation  is  on  the  glans 
penis,  a  "  coppery  "  desquamating  papule  may  be  the  only  sign  of 
the  implantation  of  disease,  and  the  typical  Hunterian  chancre  does 
not  follow.  It  is  important  to  recognise  such  a  variety  as  this,  as  it 
may  be  readily  overlooked  by  the  patient,  and  even  by  the  medical 
man,  so  that  the  disease  may  be  untreated  in  its  earlier  stages,  when 
it  is  essential  that  thorough  treatment  should  be  carried  out.  It  seems 
also  that  such  chancres  are  sometimes  followed  by  secondar}'  symp- 
toms of  so  slight  a  character  as  to  pass  unnoticed,  but  it  is  just  in 
these  cases  that  degeneration  of  the  central  nervous  system  and 
of  the  vessels  often  follows  in  middle  life.  In  other  cases  the  in- 
fection is  of  the  mixed  variety,  i.e.  the  virus  of  "soft"  and  of  "hard" 
chancre  are  implanted  at  the  same  time,  and  one  or  more  of  the 
soft  chancres  may  heal,  and  then  undergo  the  characteristic  in- 
duration of  syphilis,  and  a  hard  chancre  ensues.  The  indura- 
tion may  be  like  a  piece  of  parchment  or  a  button  let  into 
the  mucous  membrane  or  skin.  It  lasts  for  a  variable  time,  for 
about  two  to  four  months,  and  then  the  ulcer  heals  and  a  scar  is 
left.  In  women  chancres  on  the  mucous  membrane  of  the  genitals 
are  by  no  means  so  well  marked  nor  so  well  defined  as  in  men. 
The  diagnosis  of  a  typical  hard  chancre  is  not  difficult,  but  the 
identification  of  the  disease  when  the  desquamating  papule,  or 
when  soft  chancres  are  present,  and  when  the  hard  chancre  has  been 
irritated  by  caustics,  so  that  it  suppurates,  is  not  easy.  A  chancre 
and  herpes  of  the  penis  are  sometimes  confused. 

From  the  seat  of  inoculation  the  virus  spreads  to  the  lymphatic 
glands  of  the  groin  and  these  become  enlarged  and  hard.  They 
are  painless,  non-adherent  to  the  skin,  and  do  not  suppurate  unless 
the  chancre  be  irritated  or  be  of  the  mixed  variety,  i.e.  "  hard  "  and 


SYPHILIS  385 

they  often  stand  apart  and  slope  towards  each  other,  they  are 
pegged,  i.e.  they  are  broader  near  the  gum  than  at  their  free  edge, 
and  they  are  notched  from  the  breaking  away  of  the  central  portion 
of  the  free  edge.  The  other  mentioned  teeth,  too,  are  often 
dwarfed  and  ill-developed,  but  lack  the  characteristic  features  of  the 
central  incisors.  Incurable  nerve  deafness,  affecting  both  ears  and 
of  sudden  onset,  may  also  occur  as  a  later  sequela.  Associated 
with  the  deafness,  or  independently  of  it,  there  is  often  headache 
of  a  very-  intractable  nature.  A  subacute  symmetrical  synovitis  of 
the  larger  joints,  most  usually  the  knees,  attended  by  little  or 
no  pain,  is  very  rare  apart  from  inherited  syphilis.  The  only 
skin  affection  in  the  later  stages  is  the  gummatous  infiltration 
of  the  skin  and  subcutaneous  tissues  known  as  "syphilitic  lupus." 
This  consists  usually  of  somewhat  large  patches  of  inflammation 
and  hardening  of  the  cutaneous  tissues,  breaking  down  in  some 
places  into  deep  ulceration,  and  healing  in  others  with  persistent 
serpiginous  scarring.  Interstitial  keratitis  is  seldom  seen  before 
the  age  of  seven  years,  and  is  commonest  between  this  age  and 
puberty,  but  may  come  on  at  the  age  of  twenty  or  later.  Both 
eyes  are  invariably  affected,  but  one  is  usually  attacked  before 
the  other.  Iritis  is  occasionally  met  with.  Nodes  on  the  long 
bones,  and  gummata  in  the  skin,  abdominal  viscera,  and  the 
brain  and  elsewhere,  may  appear  at  any  age  after  infancy^  but 
are  commonest  at  the  times  when  interstitial  keratitis  usually 
appears.  One  case,  at  least,  is  on  record  where,  in  addition  to 
nodes,  there  was  a  diffuse  osteitis  of  the  right  tibia,  leading  to 
partial  gigantism  of  the  limb.  In  older  children,  usually  at  the  age 
of  puberty,  gummata  may  occur  in  the  tongue  and  soft  palate,  and, 
breaking  down,  may  lead  to  perforation  and  destruction  of  the  last. 
Care  should  be  taken,  however,  to  make  sure  that  such  cases  are 
not  of  the  acquired  disease,  as  this,  unfortunately,  is  by  no  means 
a  rarity  in  children.  Syphilitic  orchitis  occasionally  occurs  soon 
after  infancy,  but  is  commonest  at  the  usual  times  of  the  later 
manifestations.  Lardaceous  disease  is  almost  unknown  at  any 
stage  of  the  inherited  complaint,  but  it  is  quite  conceivable  that  it 
might  occur  in  the  rare  event  of  suppurative  bone  lesions  of  long 
persistence.  In  a  few  instances  locomotor  ataxia,  commencing  at 
the  early  age  of  puberty,  has  followed  on  inherited  syphilis  in 
infancy,  and  it  is  stated  by  some  alienists  that  general  paralysis  of 
the  insane,  when  developed  in  early  Hfe,  is  invariably  attributable 
to  this  cause. 

It  must  be  strictly  remembered    that,   with    the   exceptions  of 

VOL,  I  2  C 


386  MANUAL  OF   MEDICINE 

Hutchinsonian  teeth  and  interstitial  keratitis,  any  of  the  above- 
mentioned  later  manifestations  of  inherited  syphilis  are  very  ex- 
ceptional in  occurrence. 

Acquired  syphilis  in  infants. — From  the  nature  of  things, 
acquired  syphilis  is  of  necessity  an  extreme  rarity  in  infants.  As 
with  adults,  it  can  only  occur  through  the  agency  of  a  primary 
chancre,  and  the  periods  of  primary  and  secondary  incubation  are 
the  same  at  all  stages  of  life.  Acquired  syphilis  in  infants  does  not 
differ  materially  in  its  manifestations  from  the  same  complaint  in 
adults,  although  it  markedly  does  so  from  the  inherited  form  in 
many  respects.  In  the  acquired  syphilis  of  infants  there  is  an 
absence  of  the  bony  affections  of  the  skull,  the  early  involvement  of 
the  abdominal  viscera,  and  the  specific  epiphysitis,  all  of  which  are 
frequent  and  characteristic  of  the  inherited  form,  and  marasmus  and 
snuffles  are  much  less  prominent  features  in  the  former  than  in  the 
latter  complaint.  The  throat  and  fauces  are  affected  in  the  same 
manner,  and  at  the  same  time,  in  the  infantile  acquired  form  as  in 
the  adult  one,  and  the  usual  eruptions  are  the  same  in  both.  The 
eruptions,  too,  are  chiefly  manifested  over  the  front  of  the  trunk  and 
flexor  surfaces  of  the  limbs,  and  show  no  peculiar  predilection  for 
the  buttocks  and  chin,  as  in  the  inherited  form.  A  marked  feature 
of  the  acquired  form  in  infancy  is  the  scanty  development  and 
evanescent  nature  of  the  eruptions,  and  the  early  and  luxuriant 
growth  of  condylomata.  The  power  of  infecting  the  healthy,  more- 
over, is  vastly  greater  in  the  acquired  than  in  the  inherited  form  in 
infancy. 

Diagnosis. — The  diagnosis  of  acquired  syphilis  in  infants  is 
precisely  the  same  as  in  adults.  That  of  inherited  syphilis  is 
perfectly  simple  in  the  majority  of  instances ;  the  marked  snuffling, 
the  character  of  the  eruptions,  and  their  pecuUar  selection  of  sites 
leave  little  room  for  error  or  doubt.  The  snuffles  may  long  precede 
any  other  symptom,  and  cases  of  marked  and  persistent  snuffles, 
even  with  a  total  absence  of  all  other  signs,  are  most  probably  due 
to  syphilis.  Obstinate  and  progressive  wasting,  especially  if  un- 
associated  with  any  obvious  digestive  disturbance,  is  not  very  un- 
frequently  the  only  objective  sign  of  the  inherited  complaint.  The 
diagnosis  in  some  of  these  last  cases  may  be  supported  by  the 
peculiar  "  cafe-au-lait  "  tint  of  the  skin  which,  as  Henoch  has  pointed 
out,  is  confined  to  the  marasmic  cases,  and  not  to  those  of  syphilis 
in  general,  as  Trousseau  supposed.  In  some  cases  pseudo-paralysis 
or  epiphysitis  may  be  the  first  symptom  to  call  attention  to  the 


SYPHILIS  387 

malady,  and  In  others,  but  very  rarely,  enlargement  of  the  spleen 
may  furnish  the  only  evidence  of  it.  A  single  well-formed  mucous 
tubercle,  or  condyloma,  is  absolutely  pathognomonic  of  syphilis. 
The  family  history  as  regards  miscarriages  and  snuffles  and  rash  in 
the  older  children  is  of  prime  importance,  as  it  may  help  to  confirm 
the  diagnosis  in  the  better  marked  cases,  and  in  the  more  doubtful 
ones  it  may  furnish  evidence  of  more  value  than  the  existing  clinical 
signs.  Even  after  the  intelligent  use  of  all  available  criteria,  there 
still  remains  a  large  class  of  cases  in  which  the  diagnosis  is  a  matter 
of  doubt.  In  such  cases  snuffles,  rash,  and  other  symptoms  may  be 
so  ill-developed,  and  the  family  history  so  dubious,  that  a  confident 
diagnosis  is  only  possible  with  the  self-sufficient.  Here  recourse 
may  be  made  to  the  effect  of  treatment.  Many  such  doubtful 
cases,  it  is  true,  improve  and  recover  under  the  administration  of 
mercury.  But  it  must  be  remembered  that  many  infants  who  are 
not  syphilitic  improve  under  mercury,  and  in  the  case  of  syphilis, 
as  in  other  diseases,  a  diagnosis  founded  upon  the  mere  effects  of 
treatment  can  never  be  one  that  is  quite  satisfactory  or  convincing. 

Prognosis. — In  cases  presenting  signs  of  the  disease  at  birth 
the  prognosis  is  all  but  fatal.  It  is  equally  so  in  those  in  which 
jaundice  or  pemphigus  supervene.  Wasting  dating  from  birth  is 
seldom,  if  ever,  recovered  from,  and  the  prognosis  attaching  to 
wasting  in  later  months  is  scarcely  more  hopeful.  Unfavourable 
signs  are  an  early  appearance,  or  extensive  development,  of  the 
eruption,  and  any  undue  enlargement  of  the  abdominal  viscera. 
Cases  where  the  rash  is  pustular  from  the  onset  generally  die.  Of 
the  rest  of  the  cases,  if  the  infant  be  well  nourished,  and  if  the 
symptoms  have  not  appeared  before  the  beginning  of  the  second 
month,  the  prognosis  is  good.  As  regards  the  future,  too,  it  is  only 
a  small  minority  of  those  surviving  the  stage  of  infancy  that  present 
signs  of  the  complaint  in  later  years.  Children,  however,  who 
have  seemingly  recovered  from  inherited  syphilis  are  much  more 
prone  to  succumb  to  the  stress  of  other  disorders  than  those  less 
heavily  handicapped  at  the  start  of  life. 

Treatment. — The  essentials  of  treatment  are  comprised  in  the 
maintenance  of  nutrition  and  the  due  administration  of  mercury. 
For  the  first  of  these  it  is  a  bounden  duty  that  the  mother  should, 
if  possible,  suckle  her  infant.  If  she  be  seemingly  healthy,  the 
small  chance  there  may  be  of  her  contracting  the  disease  from  her 
infant  by  suckling  it  ought  to  be  incurred.  The  great  mortality 
amongst  syphilitic  infants  lies  largely  amongst  those  that  are  hand- 
fed,  and  the  difference  between  suckling  and  hand-feeding  means 


388  MANUAL  OF  MEDICINE 

possibly  one  between  life  and  death  for  many  an  infant.  When  the 
mother  cannot  suckle  it,  the  infant  must  be  either  wet-nursed  or  hand- 
fed.  The  questions  as  to  the  dangers  incurred  by  a  healthy  wet- 
nurse,  and  the  details  involved  in  a  proper  system  of  hand-feeding, 
are  too  lengthy  for  discussion  here.  It  cannot,  however,  be  too 
emphatically  asserted  that  a  proper  diet  is  equally  important  with 
the  drug  treatment  of  the  complaint. 

For  the  second  essential  in  treatment,  the  administration  of 
mercury,  only  two  methods  need  be  considered,  that  of  giving  it  by 
the  mouth,  and  that  by  inunction.  The  former  has  two  strong  recom- 
mendations in  its  favour — simplicity  and  efficacy.  The  usual  prepara- 
tion given  is  the  ordinary  grey  powder,  and  this  generally  meets 
all  the  requirements  of  most  cases.  It  can  be  given  in  doses  of  one 
grain  three  times  a  day  to  infants  of  all  ages.  Given  in  these  doses 
it  rarely,  if  ever,  causes  diarrhoea,  and  if  the  latter  supervene,  it  is 
generally  due  to  some  error  in  diet,  or  to  the  fact  that  the  complaint 
is  epidemic  at  the  time.  When  diarrhoea  is  present,  each  dose  of 
the  grey  powder  can  be  combined  with  a  third  or  half  of  a  grain  of 
Dover's  powder,  according  to  the  age  of  the  infant.  If  in  spite  of 
this  addition  the  diarrhoea  should  persist,  or  if  it  be  considered  that 
the  internal  administration  of  mercury  causes  digestive  disturbance, 
then  recourse  can  be  had  to  the  method  of  inunction.  In  this  last, 
from  twenty  grains  to  half  a  drachm  of  mercury  ointment  should  be 
rubbed  into  the  inner  sides  of  the  thighs  or  the  axillae,  or  upon  the 
surface  of  the  belly  binder,  once  a  day.  Under  such  a  treatment 
it  is  undoubted  that  the  eruptions  and  other  manifestations  of  the 
disease  rapidly  disappear.  The  amount  of  mercury  absorbed  by 
the  skin,  however,  is  an  uncertain  quantity,  and  some  observers, 
believe  that  more  infants  treated  by  inunction  come  back  in  later 
months  presenting  symptoms  of  the  disease  than  is  the  case  with 
those  who  have  been  treated  with  mercury  by  the  mouth.  If  this 
be  so,  then  the  method  of  administration  by  the  mouth  should  have 
preference,  unless  otherwise  contra-indicated,  over  that  of  inunction. 
Whichever  method  be  adopted,  the  treatment  should  be  faithfully 
carried  out  for  a  course  of  at  least  four  months'  duration,  and  longer 
if  any  symptoms  are  present.  The  fear  of  causing  symptoms  like 
those  belonging  to  the  salivation  of  adults  can  be  dismissed  ;  such 
salivation  is  practically  unknown  in  infants. 

Except  in  the  rare  contingency  of  nodes  or  gummata  being 
present,  there  is  no  need  of  any  addition  of  the  iodides  to  the 
mercury  given.  The  iodides  merely  assist  in  the  more  speedy 
removal  of  such  complications,  and  have  no  real  power  in  the  way 


RABIES  389 

of  curing  the  disease.     For  this  last,  mercury  is  all  essential  at  all 
stages. 

If  the  nasal  discharges  cause  blocking,  a  two  per  cent  solution  of 
the  oleate  of  mercury,  or  a  little  dilute  ammoniated  mercury  oint- 
ment, should  be  passed  into  the  nostril  with  a  camel's  hair  brush. 
Condylomata  should  be  dusted  with  calomel,  and  if  long  persisting, 
be  lightly  touched  over  with  one  of  the  ordinary  caustics.  In  the 
event  of  ulceration  of  any  moment  occurring,  then  the  mercury 
given  should  be  supplemented  by  doses  of  opium  appropriate  to  the 
age  of  the  child.  In  all  the  ulcerative  conditions  of  infancy, 
syphilitic  or  otherwise,  there  is  no  drug,  perhaps,  of  such  value  as 
opium. 

J.    A.    COUTTS. 


RABIES 
Syn.  Hydrophobia 


An  acute  infective  malady  of  the  central  nervous  system,  the 
symptoms  being  dependent  on  the  action  of  a  poison  which  is 
developed  throughout  these  organs,  but  more  especially  in  the 
medulla. 

Rabies  or  hydrophobia  is  a  disease  that  is  sometimes  very 
prevalent  in  animals,  and  is  occasionally  seen  in  man.  The  name 
of  rabies  is  usually  restricted  to  the  disease  in  the  former,  and  the 
term  hydrophobia  used  for  the  same  malady  in  man.  Hydrophobia 
is,  however,  a  misnomer,  since  there  is,  strictly  speaking,  no  fear  of 
water,  but  only  a  difficulty  in  swallowing,  more  marked  with  liquids 
than  with  solids. 

Occurrence  in  animals. — Rabies  is  most  prevalent  in  dogs, 
cats,  wolves  and  foxes ;  it  is  occasionally  seen  in  horses,  very 
rarely  in  pigs,  and  several  outbreaks  have  occurred  in  deer.  The 
frequency  of  rabies  in  the  carnivora  is  associated  with  the  fact  that 
it  is  usually  propagated  by  biting. 

It  is  met  with  both  sporadically  and  in  epidemics,  and  frequently 
the  latter  can  be  traced  to  foci  of  the  disease  in  certain  parts  of 
the  country  where  it  may  be  more  or  less  endemic,  and  at  intervals 
affecting  large  numbers  of  animals  over  wide  tracts  of  councry.  In 
certain  districts  it  is  unknown,  as,  for  instance,  in  Norway  and 
Australia.     It  is  rare  in  Germany,  but  it  is  more  comrnon  in  France 


39°  MANUAL  OF  MEDICINE 

and  Russia,  and  also  in  the  East.  In  this  country  the  incidence 
of  the  malady  varies  considerably;  in  the  years  1895  and  1896 
there  was  an  extensive  outbreak,  but  at  the  present  time,  1899, 
the  disease  has  greatly  diminished  in  amount. 

Virus  of  rabies. — The  virus  of  rabies  is  remarkable  in  the 
fact  that  it  is  distributed  throughout  the  nervous  system,  central  and 
peripheral.  In  addition  to  this  it  is  found  in  the  secretion  of 
certain  glands,  such  as  the  salivary  (especially  the  parotid),  the 
lachrymal,  the  mammary,  and  the  pancreas.  The  virus  is  not 
found  in  the  blood,  tissues,  urine,  nor  in  other  excretions.  When 
the  malady  is  fully  established,  and  a  fortiori  at  death,  it  is  found 
throughout  the  nervous  system  ;  in  the  earlier  stages  of  the  disease, 
however,  it  is  limited  to  the  medulla.  The  virus  of  rabies  is  com- 
paratively readily  destroyed  by  the  action  of  sunlight,  by  heat,  by 
dessication,  and  by  the  action  of  powerful  antiseptics.  Putrefaction 
destroys  its  activity  more  slowly,  and  the  carcase  of  an  animal  dead 
from  rabies  has  been  found  virulent  as  long  as  forty-five  days  after 
burial. 

Mode  of  infection. — Rabies  is  usually  communicated  both 
to  animals  and  to  man  by  the  bite  of  the  rabid  animal  infecting  the 
wound  by  means  of  the  saliva.  It  is  for  this  reason  that  hydro- 
phobia is  more  frequent  after  bites  on  exposed  surfaces,  such  as 
the  face  and  hands,  than  when  the  person  is  bitten  through  clothes. 
Similarly  animals  covered  with  fur  are  less  liable  to  contract  the 
malady  when  bitten  than  shaved  animals,  or  animals  destitute  of 
fur.  The  disease  is  not  communicable  from  one  animal  to 
another  by  the  carcase  of  the  rabid  animal  being  eaten  by  another. 
It  is  probable  that  infection  is  more  readily  conveyed  if  the  injury 
involve  a  nerve,  as  it  has  been  shown  that  the  virus  travels  along 
the  nervous  system  from  the  periphery  to  the  centre.  Thus,  if 
the  spinal  cord  be  experimentally  divided  in  the  mid-dorsal  region, 
and  inoculation  of  the  virus  of  rabies  be  made  in  the  posterior  half  of 
the  body,  the  lower  segment  of  the  spinal  cord  will  contain  the  virus 
at  a  time  when  the  upper  half  is  free  from  it.  From  this  it  is  held 
that  the  virus  is  propagated  through  the  nervous  system,  and  is  not 
conveyed  from  the  peripheral  to  the  central  nervous  structures  by 
the  lymph  or  blood.  Deep  lacerated  wounds  involving  the  muscular 
planes  are  more  liable  to  be  followed  by  rabies  than  superficial 
wounds  involving  the  skin  and  subcutaneous  tissue.  It  is  estimated 
that  in  the  human  subject  from  16  to  25  per  cent  of  persons 
bitten  by  rabid  animals  contract  hydrophobia,  the  others  escape 
for  various  reasons,  but   more  especially  from  the  clothes,    boots, 


RABIES  391 

etc.,  preventing  the  inoculation  of  the  wound.  Bites  inflicted  by 
a  rabid  wolf  or  cat  are  more  liable  to  communicate  the  disease  to 
man  owing  to  the  greater  likelihood  of  the  exposed  parts  of  the 
body  being  bitten. 

The  incubation  period  of  rabies  varies  greatly.  In  man 
it  is  usually  six  weeks,  but  it  has  been  asserted  that  it  may  be  as 
short  as  three  weeks,  and  as  long  as  twelve  or  eighteen  months ; 
in  some  quite  exceptional  cases  an  incubation  period  of  from  two 
to  five  -years  has  been  described.  In  animals  the  incubation 
period  varies  with  the  species.  Thus  in  dogs  it  ranges  from 
fifteen  to  sixty  days,  and  in  at  least  50  per  cent  it  is  less  than  a 
month,  whilst  it  is  rare  after  120  days.  In  cattle  the  incubation 
period  varies  from  one  to  three  months.  In  the  rabbit  it  is  usually 
fourteen  to  nineteen  days.  The  variation  in  the  duration  of  the  in- 
cubation period  depends  to  a  great  extent  on  the  degree  of  virulence 
of  the  poison,  and  in  street  rabies,  la  rage  des  rues,  there  are  great 
individual  variations.  In  the  laboratory,  however,  by  transmitting 
rabies  from  one  animal  to  another  by  inoculation,  it  is  possible  to 
elaborate  a  virus  in  which  the  incubative  period,  at  any  rate  in  the 
rabbit,  becomes  fixed  at  seven  days. 

Symptoms. — During  the  incubation  period,  both  in  animals 
and  man,  there  is  but  little  to  be  noted,  and  usually  the  wound 
heals  with  no  symptoms  of  general  disturbance.  At  the  end  of 
the  period  of  incubation  the  site  of  the  wound  becomes  irritable, 
and  tingling  and  itching  may  be  noticed,  and  in  man  it  has  been 
asserted  that  the  wound  may  open  up  again.  Soon  both  in 
animals  and  in  man  restlessness,  agitation,  and  nervousness  become 
marked.  The  subsequent  course  of  the  malady  depends  on  which 
of  two  types  it  assumes.  The  most  common  clinical  type  is  that 
known  as  "furious  rabies,"  and  in  this  condition  t?i  the  dog  or 
other  animal  the  agitation  and  restlessness  become  increased,  and 
the  animal  suffers  from  hallucinations ;  at  this  time,  however,  it 
is  not  savage,  and  it  does  not  show  any  tendency  to  attack  those 
near.  Soon  the  bark  becomes  altered,  exceedingly  prolonged, 
high  pitched,  and,  to  a  certain  extent,  stridulous.  The  seat  of  the 
bite,  from  being  irritable,  becomes  anaesthetic,  and  it  is  not  un- 
common for  the  animal  to  inflict  on  itself  severe  wounds  by 
gnawing  the  part.  Some  difficulty  is  experienced  with  deglutition, 
more  especially  with  liquids ;  the  restlessness  leads  the  animal  to 
wander  about,  and  even  to  travel  long  distances,  although  at  the 
onset  of  the  malady  it  may  have  shown  a  tendency  to  withdraw 
itself  from    observation   by   hiding  in    dark   corners.      The  animal 


392  MANUAL  OF  MEDICINE 

now  rapidly  becomes  furiously  maniacal,  attacking  animate  and 
inanimate  objects,  and  biting  and  swallowing  at  this  period  all  sorts 
of  foreign  bodies,  such  as  pieces  of  wood,  bone,  coal,  rugs,  its  own 
faeces,  etc.  After  the  furious  stage  has  lasted  for  two  to  three 
days  palsy  rapidly  sets  in,  affecting  first  the  muscles  of  the  jaw, 
then  those  of  the  extremities,  and  finally  the  respiratory  muscles, 
and  so  causing  death  from  asphyxia.  The  total  duration  of  the 
illness  in  the  dog  is  usually  from  four  to  five  days ;  it  may,  how- 
ever, last  ten  days,  and  it  may  run  its  whole  course  in  two. 

The  other  clinical  variety  of  rabies  is  "dumb"  or  "paralytic 
rabies."  This  is  really  similar  to  the  terminal  phenomena  of 
furious  rabies.  Dumb  rabies  is  more  especially  characteristic  of  the 
disease  in  the  rabbit  and  rodents  generally.  It  is,  however,  occa- 
sionally seen  in  dogs,  and  it  is  probable  that  it  has  occurred  in 
man.  In  dumb  rabies  the  sensory  troubles  are  not  marked.  The 
dog  is  anxious  and  agitated,  and  this  condition  is  rapidly  followed 
by  paralysis,  affecting,  it  may  be,  the  jaw,  or  causing  paraplegia  or 
hemiplegia,  or  even  monoplegia.  In  dumb  rabies  the  animal  is 
necessarily  unable  to  bite,  and  the  disease  is  of  far  shorter  duration, 
viz.  two  to  three  days.  The  urine  frequently  contains  sugar,  both 
in  dumb  rabies  and  in  the  later  stages  of  furious  rabies. 

In  ma?t  during  the  early  stages  the  patient  is  anxious,  fearful, 
depressed,  often  complains  of  thirst,  and  there  is  marked  pallor. 
He  is  quite  conscious  and  rational,  and  able  to  talk,  although  even 
at  the  early  stages  respiration  is  slightly  interfered  with,  leading  to 
interruption  of  his  sentences ;  the  restlessness  and  ■  agitation  in- 
crease, but  the  most  striking  phenomenon  which  the  writer  has 
seen  in  three  cases  of  hydrophobia  is  the  intense  fearfulness  of  the 
patients  and  their  extreme  dread.  Slight  and  intermittent  delirium 
may  be  present  and  delusions  may  supervene,  exceptionally  the 
delirium  passes  into  maniacal  excitement.  Thirst  is  a  prominent 
symptom,  but  there  is  great  difficulty  in  deglutition,  especially 
of  liquids,  and  any  attempt  to  swallow  causes  violent  spasmodic 
contraction  of  the  muscles  of  deglutition,  so  that  the  fluid  is  often 
expelled  from  the  mouth.  Very  soon  the  spasmodic  contractions 
spread  to  other  muscles,  more  especially  those  of  respiration,  and 
general  convulsive  attacks,  with  marked  opisthotonos,  supervene 
and  recur  at  every  attempt  to  swallow.  These  attacks  rapidly 
exhaust  the  patient,  the  pulse  becoming  quick  and  irregular;  the 
convulsive  seizures  increase  in  frequency,  and  death  usually  super- 
venes from  asphyxia.  The  convulsive  attacks  are  in  the  fully 
established  disease  produced  not  only  by  attempts  at  swallowing,, 


RABIES  393 

but  also  by  slight  reflex  stimuli,  such  as  a  draught  of  air,  or  a  strong 
light,  etc.  During  the  convulsive  seizures  the  mental  excitement  of 
the  patient  is  greatly  increased.  In  very  exceptional  cases  a  condition 
similar  to  that  of  paralytic  rabies  has  been  seen  in  the  human  sub- 
ject, namely,  a  rapid  ascending  palsy,  affecting  first  the  extremities, 
and  then  the  muscles  of  respiration.  It  is  possible  that  some  of  the 
cases  described  formerly  under  the  term  of  Landry's  paralysis  may 
really  have  been  cases  of  paralytic  rabies.  There  is  usually  slight 
fever  at-  the  onset  of  the  malady,  and  the  temperature  may  rise  to 
105°  F.     Albumen  and  sugar  may  be  present  in  the  urine. 

The  statement  that  the  patient  barks  like  a  dog  has  arisen  from 
the  fact  that  the  accumulation  of  mucus  in  the  throat,  together 
with  the  partial  palsy  of  the  respiratory  muscles,  leads  to  a  peculiar 
cough ;  and  the  frothing  at  the  mouth  sometimes  described  is  due 
to  the  unswallowed  saliva  and  mucus  which  hangs  about  the  lips. 

The  duration  of  the  disease  in  man  is  usually  two  to  four  days. 

Morbid  anatomy. — In  animals  the  mucous  membrane  of  the 
mouth,  the  tongue  and  larynx  are  congested  and  covered  with  an 
abundant  dry  mucus.  The  stomach,  especially  in  the  dog,  con- 
tains no  food,  but  a  number  of  substances  of  the  most  diverse 
description  ;  frequently  there  are  petechial  haemorrhages  in  the 
mucous  membrane  and  even  haemorrhagic  ulcers;  these  may  also 
be  present  in  the  intestines.  The  spinal  bulb  and  brain  are  usually 
congested.  Other  lesions,  such  as  petechial  extravasations  in  the 
serous  membranes,  are  perhaps  more  dependent  on  the  mode  of 
death  than  on  the  action  of  the  virus  of  rabies.  It  is  difficult  to 
diagnose  rabies  from  a  post-mortem  examination  in  animals,  and  is 
frequently  impossible  owing  to  the  fact  of  the  animal  having  been 
killed  at  an  early  stage  of  the  disease  before  the  lesions  are  fully 
developed,  and  it  is  for  this  reason  that  the  experimental  diagnosis 
by  inoculation  is  of  much  value.  The  combination  of  the  absence 
of  food  and  the  presence  of  a  great  variety  of  foreign  bodies  in  the 
stomach  is  suggestive. 

In  man  the  main  post-mortem  features  are  the  congestion  of  the 
fauces,  larynx,  trachea,  ston  ach,  and  also  of  the  central  nervous 
system  and  meninges.  Microscopically,  hemorrhages  have  been 
found  by  Gowers  and  others  in  the  nerve  centres,  more  especially 
in  the  fourth  ventricle.  Several  observers  have  noted  objective 
changes  in  the  cells  of  the  bulb  and  even  the  presence  of  collections 
of  leucocytes,  to  which  Gowers  gave  the  name  of  "  miliary  abscess  " 

Diagnosis. — In  diagnosing  rabies,  both  in  animals  and  in  man, 
three  methods  are  open  to  us — by  the  clinical  characters,  by  the 


394  MANUAL  OF  MEDICINE 

post-mortem  appearances,  and  by  experimental  inoculation.  Clinic- 
ally the  most  satisfactory  method  in  animals  is  to  isolate  the  sus- 
pected animal  with  due  regard  to  the  safety  of  others ;  if  it  be 
rabid,  death  will  soon  supervene  with  the  characteristic  paralytic 
symptoms,  as  the  course  of  the  disease  is  short  after  the  establish- 
ment of  the  initial  symptoms.  On  the  other  hand,  if  the  suspected 
animal  be  killed,  it  may  take  several  weeks  to  determine  the  exist- 
ence of  rabies  by  inoculation,  and  it  is  impossible  to  diagnose  rabies 
on  post-mortem  examination  in  the  early  stages  of  the  disease.  The 
most  common  diseases  in  dogs  mistaken  for  rabies  are  epilepsy, 
epileptiform  seizures  as  a  result  of  ear  disease,  and  enteritis.  The 
impaction  of  a  foreign  body  in  the  throat  often  leads  to  a  mistaken 
diagnosis  of  dumb  rabies  in  animals. 

In  the  human  subject  hystero- epilepsy,  mania,  tetanus,  and 
Landry's  paralysis  are  the  maladies  most  apt  to  be  confounded  with 
hydrophobia.  It  is  more  difficult  to  separate  mania  than  hystero- 
epilepsy  from  rabies,  but  such  patients  do  not  suffer  from  the 
characteristic  respiratory  spasm  which  is  seen  in  hydrophobia. 
Tetanus  which  may  follow  the  bite  of  a  dog  has  a  shorter  incuba- 
tion period  and  there  is  not  that  peculiar  fearful  expression  that  is 
so  characteristic  of  rabies. 

The  term  "lyssophobia"  has  been  applied  to  a  group  of  symptoms 
occurring  in  persons  who  are  in  great  dread  of  rabies  after  having 
been  bitten  by  an  animal  not  necessarily  rabid.  A  difficulty  in 
swallowing,  resembling  the  globus  hystericus,  together  with  hysterical 
convulsions,  form  the  prominent  symptoms.  True  spasm  of  respira- 
tion, such  as  is  seen  in  rabies,  is,  however,  absent.  The  real  malady 
has  more  often  been  thought  to  be  spurious  than  the  converse. 

After  death  the  diagnosis  of  rabies  can  be  made  with  certainty  by 
inoculation  of  an  emulsion  of  the  medulla  from  the  suspected  case. 
It  is  possible,  however,  that  putrefaction  may  in  some  cases  prevent 
the  detection  of  rabies  even  when  present.  The  suspected  medulla 
or  spinal  cord  should  be  placed  in  glycerine  for  two  or  three  days. 
An  emulsion  of  it  should  then  be  made  in  sterilised  salt  solution  or 
broth  and  a  few  drops  injected  subdurally  in  the  rabbit.  This  plan 
is  followed  because  it  is  the  most  certain  method  of  communicating 
the  disease,  but  inoculation  into  the  aqueous  humour  is  also 
efficacious.  If  the  virus  of  rabies  is  present  the  rabbits  develop 
paralytic  rabies  after  an  incubative  period  of  from  fourteen  to  nine- 
teen days,  sometimes,  however,  prolonged  to  six  weeks.  The 
characteristic  features  of  this  experimental  rabies  in  the  rabbit  are 
a   progressive   paralysis   occurring  at   the    time   when    the   general 


RABIES  395 

nutrition  of  the  animal  is  still  good  and  accompanied  with  attacks 
of  clonic  spasm  and  dyspncea.  The  mere  occurrence  of  palsy  of 
the  extremities  is  not  sufficient  to  diagnose  rabies  experimentally. 
The  rabbits  usually  live  for  two  or  three  days  after  the  onset  of 
palsy.  The  only  fallacies  in  this  method  are,  on  the  one  hand,  that 
exceptionally  the  presence  of  putrefaction  in  the  suspected  spinal 
cord  has  prevented  the  development  of  rabies  owing  to  the  destruc- 
tion of  the  virus,  and,  secondly,  that  if  the  spinal  cord  is  contaminated 
with  some  other  virus,  as  for  instance  that  of  septicaemia,  the 
inoculated  animals  may  die  before  the  incubation  period  of  rabies 
has  elapsed.  This  method  of  diagnosis  is  equally  applicable  to  the 
spinal  cord  or  medulla  of  man,  and  has  been  of  use  on  several 
occasions  in  determining  whether  a  patient  has  succumbed  to  mania 
or  to  rabies. 

Treatment. — The  part  bitten  should  be  washed  as  soon  as 
possible,  and  temporary  compression  above  the  seat  of  the  bite  to 
delay  and  prevent  absorption  should  be  employed.  The  wound 
should  then  be  thoroughly  cauterised  with  strong  nitric  acid  or 
with  some  strong  antiseptic,  such  as  carboHc  acid.  Nitrate  of 
silver  is  not  so  efficacious  as  nitric  acid  and  the  latter  should  be 
used  if  possible. 

The  fully-established  disease  in  man  is  beyond  treatment,  the 
only  thing  that  can  be  done  is  to  keep  the  patient  absolutely  quiet 
in  a  darkened  room  and  to  combat  the  violence  of  the  spasms 
by  chloroform  or  chloral.  The  Pasteur  treatment  is,  however,  of 
the  greatest  value  in  preventing  the  development  of  rabies  both 
in  animals  and  in  man  after  exposure  to  the  virus.  It  is 
essential  that  that  treatment  should  be  entered  upon  with  as 
little  delay  as  possible,  and  it  is  most  unwise  for  the  victim  bitten 
by  an  animal  to  wait  until  the  inoculation  of  rabbits  with  the 
suspected  material  has  shown  the  animal  to  be  rabid ;  in  this  way 
three  weeks  may  be  lost,  and  the  disease  may  declare  itself  before 
the  protective  inoculations  can  be  carried  out.  If,  after  a  person 
has  been  bitten,  the  suspected  animal  be  isolated,  a  delay  of  a  very 
few  days  will  determine  whether  there  is  or  is  not  reasonable  ground 
for  looking  upon  the  case  as  one  of  rabies,  and  the  inoculation  test 
can  then  be  used  to  confirm  this,  but  if  there  are  good  grounds 
for  suspecting  the  animal  to  be  rabid  the  Pasteur  treatment  of  the 
person  bitten  should  not  be  delayed  for  the  results  of  the  inocula-' 
tion  test.  The  essence  of  the  Pasteur  treatment  is  to  inject  sub- 
cutaneously  an  emulsion  prepared  from  dessicated  spinal  cords  of 
rabbits  which  have  been  inoculated  with  rabies.     The  potency  of 


396  MANUAL   OF   MEDICINE 

the  virus  is  gradually  destroyed  by  dessication,  and  in  this  way  by 
varj-ing  the  period  of  dessication  a  series  of  emulsions  of  gradually 
increasing  strengths  can  be  prepared.  The  injection  of  these  not 
only  does  not  produce  rabies  but  renders  the  animal  or  person 
immune  to  rabies  at  any  rate  for  a  time.  The  statistics  of  the 
Pasteur  Institute  not  only  show  the  great  value  of  the  treatment  in 
preventing  the  onset  of  hydrophobia  in  those  bitten  by  rabid 
animals,  but  they  also  show  that  the  modern  treatment  as  conducted 
there  is  free  from  risk, 

John  Rose  Bradford. 


FOOT   AND    MOUTH    DISEASE 
SvN.  Aphth.«  Epizootic/e 

An  acute  febrile  affection,  the  most  prominent  feature  of  which 
is  a  vesicular  eruption,  occurring  chiefly  on  the  mucosa  of  the 
mouth,  but  also  on  the  skin  of  the  hands  and  feet,  and  sometimes 
on  other  parts  of  the  body. 

This  epizootic  malady,  said  to  have  been  first  imported  into 
England  in  1839,  chiefly  affects  ruminants  and  pigs,  but  is  trans- 
missible to  man.  The  contagium  may  be  conveyed  directly  or  in- 
directly, that  is  to  say,  it  may  be  inoculated  on  a  sore,  or  wound  of 
the  skin,  or  mucous  membrane,  or  the  infection  may  be  derived 
from  partaking  of  tainted  milk,  butter,  or  cheese. 

Notwithstanding  the  severe  and  extensive  outbreak  among  the 
cattle  in  the  British  Islands  between  1876  and  1885,  when  the 
numbers  attacked  were  counted  by  hundreds  of  thousands,  and  a 
further  outbreak  in  1892  of  over  5000  cases,  English  medical 
literature  relative  to  human  infection  seems  confined  to  a  few 
scattered  cases,  and  an  epidemic  at  Dover  in  1884,  where  144 
persons  were  attacked.  Therefore,  either  the  disease,  if  it  have 
occurred,  has  not  been  recognised  as  such,  and  has  been  assigned 
to  some  other  cause,  or  the  transmission  of  the  infection  to  man  is 
attended  with  some  difificulty.  On  the  continent  of  Europe,  how- 
ever, it  seems  to  be  fairly  common,  and  there  aphthous  stomatitis 
in  children  is  almost  invariably  assigned  to  infected  milk  and  to  a 
bovine  origin. 


FOOT  AND   MOUTH   DISEASE  397 

The  virus.— The  actual  exciting  cause  is  still  undecided,  but 
claims  have  been  raised  on  behalf  of —  a  streptococcus  (Klein, 
Kurth) ;  a  bacillus,  pure  cultures  of  which  are  stated  to  reproduce 
the  disease  (Starcovici) ;  a  protozoon,  Protamoeba  aphthogenes^  which 
_has  been  detected  in  the  vesicles  and  circumjacent  tissue  (Plana 
and  Fiorentini).  But  whatever  the  virus  may  be  it  is  certain  that 
it  is  highly  contagious  to  cattle,  and  may  retain  its  infective  power 
for  quite  three  months. 

The  incubation  period  in  cattle  is  stated  to  be  a  week,  but  in 
man  it  varies  from  two  to  eight  days,  the  difference  probably 
depending  on  the  direct  or  indirect  method  of  infection. 

Symptoms. — The  disease  declares  itself  by  a  rigor,  soon 
followed  by  pyrexia  (ioi°-io2°),  malaise,  and  headache.  The 
mouth  feels  hot  and  dry,  and  the  feet  and  hands  may  burn  and 
.tingle.  After  lasting  two  to  seven  days  the  general  symptoms  are 
followed  by  an  eruption  of  small  vesicles  on  the  mucosa  of  the 
mouth,  any  part  of  which  may  be  affected,  on  the  skin  of  the  hands 
and  feet,  and  sometimes  on  other  parts  of  the  body,  notably  the 
lips  and  face. 

In  the  mouth  the  number  of  vesicles,  except  in  bad  cases,  is 
rarely  more  than  ten  or  twelve,  and  their  distribution  may  be 
discrete  or  confluent.  The  vesicles  are  small  yellowish -white 
blisters  with  turbid  fluid  contents,  and  may  attain  the  size  of  hemp 
seeds  or  even  of  peas.  After. some  hours  to  one  or  two  days  the 
vesicles  burst,  leaving  shallow  ulcers  with  red  base  and  margins. 
The  eruption  in  the  mouth  is  accompanied  by  dysphagia,  ptyalism, 
difficulty  of  speaking,  and  sometimes  by  offensive  discharge  from  the 
nose.  With  the  stomatitis  are  also  associated  pain  in  the  mouth 
and  swelling  of  the  retro-maxillary  glands.  In  severe  cases  symptoms 
of  gastro-intestinal  inflammation  may  be  present,  such  as  vomiting, 
diarrhoea,  and  occasionally  sanious  stools,  symptoms  which  suggest 
that  the  alimentary  mucosa  may  be  in  the  condition  of  aphthous 
enteritis,  as  is  the  case  in  animals. 

The  stomatitis  subsides  gradually  and  the  ulcerations  heal  in  a 
week  to  a  fortnight.  The  average  duration  of  the  disease  is  from 
two  to  three  weeks,  but  it  may  be  protracted  to  four  weeks,  or  not 
last  more  than  one. 

The  prognosis  is  extremely  favourable,  for  nearly  all  the  cases 
recover.  But  there  are  several  instances  where  young  children 
have  succumbed  to  an  attack. 

There  is  no  evidence  to  show  whether  one  attack  confers 
immunity. 


398  MANUAL  OF  MEDICINE 

The  diagnosis  should  be  comparatively  easy  if  there  be  a 
vesicular  eruption  on  the  mouth,  and  on  the  hands  and  feet, 
especially  in  the  inter-digital  folds,  occurring  in  a  district  infected 
with  the  epizootic.  In  large  towns,  however,  and  in  cases  where 
the  eruption  is  limited  to  the  mouth,  the  diagnosis  becomes  more 
speculative  ;  but  it  should  on  no  account  be  confused  with  aphthous 
stomatitis  or  with  "thrush."  The  only  disease  with  which  this 
aphthcc  epizooticse  is  likely  to  be  confounded  is  varicella.  This 
might  arise  when  the  eruption  in  foot  and  mouth  disease  is 
scattered  over  the  trunk  and  face.  These  cases  are,  however, 
rare,  and  the  converse  is  more  common ;  that  is  to  say,  the 
vesicular  eruption  is  more  frequently  confined  to  the  mouth. 

The  treatment  of  foot  and  mouth  disease  is  simple.  It  is 
advisable  to  wash  the  mouth  out  frequently  with  mild  solutions  of 
chlorate  of  potash  or  of  borax ;  to  protect  the  eruption  on  the 
hands  and  feet  from  becoming  contaminated  with  dirt,  and  dress 
them  with  lead  lotion  ;  and  to  feed  the  patient  with  a  nutritious 
and  liquid  diet. 

It  would  be  advisable  to  boil  the  milk  if  there  were  an  outbreak 
of  foot  and  mouth  disease  in  the  district. 

R.  G.  Hebb. 


COINCIDENT    OR    MIXED    INFECTIONS 

It  has  for  a  long  time  been  a  common  opinion  that  it  is  very 
rare,  if  not  impossible,  for  more  than  one  of  the  specific  infectious 
diseases  to  simultaneously  attack  the  same  individual.  This  idea, 
for  which  John  Hunter  appears  to  have  been  very  largely  responsible, 
is  still  widely  prevalent.  But  a  search  through  the  medical 
literature  of  the  past  century  will  reveal  the  error  of  his  teaching, 
and  its  final  refutation  has  been  brought  about  within  the  last  few 
years.  The  experience  of  any  of  the  large  fever  hospitals  furnishes 
ample  evidence  of  the  concurrence  in  the  same  subject  of  two  or 
more  infectious  diseases.  To  illustrate  this  statement  a  reference 
to  recent  statistical  reports  published  by  the  Metropolitan  Asylums 
Board  will  sufifice.  Of  41,483  cases  of  infectious  disease  (chiefly 
scarlet  fever,  diphtheria,  and  enteric  fever)  admitted  into  the  fever 
hospitals  of  London  during  1896  and  1897,  1191  or  2.8  per  cent 


.    COINCIDENT   OR   MIXED   INFECTIONS  399 

were  at  the  time  of  admission  suffering  from  more  than  one 
infection.  By  far  the  most  common  combination  of  diseases  was 
that  of  scarlet  fever  and  diphtheria,  589,  or  nearly  half  the  cases. 
Frequent  were  scarlet  fever  and  whooping-cough  (186);  scarlet 
fever  and  chicken-pox  (163);  diphtheria  and  measles  (66)  ;  and 
scarlet  fever  and  measles  (65).  Less  common  were  diphtheria  and 
whooping-cough  (34);  diphtheria  and  chicken-pox  (2  7) ;  and  the 
combinations  of  scarlet  fever  or  diphtheria  with  rubella  or  enteric 
fever,  of  which  there  were  but  a  few  instances.  In  addition  to 
these  cases,  however,  and  usually  in  consequence  of  their  having 
been  unwittingly  introduced  during  their  incubation  period  to  the 
general  wards,  there  were  those  in  which  the  patient  contracted  one 
infectious  disease  while  convalescing  from  another.  Thus,  among 
30,417  completed  cases  of  scarlet  fever — i.e.  the  cases  discharged 
and  fatal  during  the  years  in  question — there  were  1501  cases  of 
diphtheria,  1018  of  chicken-pox,  302  of  measles,  197  of  whooping- 
cough,  and  168  of  rubella.  The  number  of  diphtheria  cases  is  large, 
doubtless  because  many  are  included  in  which  the  diagnosis  was 
made  on  bacteriological  evidence.  Among  9789  completed  cases 
of  diphtheria  there  occurred  768  of  scarlet  fever,  100  of  chicken- 
pox,  70  of  measles,  and  38  of  whooping-cough  ;  while  among  1277 
cases  of  enteric  fever  there  were  9  each  of  scarlet  fever  and 
diphtheria. 

The  diseases  to  which  the  figures  just  given  relate  are  those 
most  prevalent  in  this  country  at  the  present  day.  But  with  them, 
as  well  as  with  one  another,  may  be  combined  the  following 
infections — smallpox,  mumps,  erj'sipelas,  t}'phus  fever,  pyemia, 
pneumonia,  syphilis,  tuberculosis,  and  malaria.  There  appears  in 
fact  to  be  no  reason  why  any  one  specific  infectious  disease  should 
not  co-exist  with  any  other.  Usually  two  only  are  met  with  at  the 
same  time;  but  the  writer  has  had  under  his  obser\-ation  several 
cases  in  which  three  or  even  four  have  attacked  the  same  patient 
within  a  ver}'  limited  period. 

Inquiry  into  the  relative  frequency  of  concurrence  shows  that 
it  depends  considerably  upon  the  etiolog}'  of  the  affections  concerned. 
For  instance,  while  it  must  be  admitted  that  the  figures  given  above 
afford  only  a  rough  estimate  of  the  comparative  frequency,  yet  it 
will  be  noticed  that  enteric  fever  does  not  often  enter  into  these 
combinations.  One  of  the  reasons  foi  this  is  that  scarlet  fever, 
diphtheria,  measles,  chicken-pox  and  whooping-cough  -ar-e  chiefly 
diseases  of  childhood,  whereas  enteric  fever  attacks  individuals  who 
have   passed   that   period   of  life,      Differences,   therefore,   of  age- 


400  MANUAL  OF  MEDICINE 

incidence,  of  seasonal  or  annual  prevalence,  and  of  virulence, 
partly  account  for  varying  frequency  of  concurrence.  But  when 
allowance  is  made  for  these  factors  it  still  appears  that  diphtheria 
and  scarlet  fever  have  a  great  liking  for  one  another,  and  that 
diphtheria  is  very  ready  to  ally  itself  with  several  of  the  other 
specific  diseases. 

Another  question  of  some  interest  is — Are  patients,  the  subjects 
of  one  infectious  disease,  more  likely,  ceteris  paribus,  to  contract 
another  if  exposed  to  its  infection  than  healthy  persons  ?  Such 
facts  as  are  forthcoming  with  respect  to  diphtheria  occurring  during 
convalescence  from  scarlet  fever  and  vice  versa  lead  us  to  answer 
the  question  affirmatively,  and  it  is  certainly  reasonable  to  suppose 
that  a  person  weakened  by  one  disease  would  less  easily  resist 
infection  by  another. 

On  one  point  clinical  experience  is  quite  clear ;  and  that  is, 
that  when  infectious  diseases  occur  together,  or  quickly  follow  one 
another  in  the  same  patient,  the  symptoms  are,  as  a  rule,  more 
serious  than  when  they  occur  alone.  The  fatality  of  diphtheria  co- 
existing with  or  immediately  following  scarlet  fever,  measles,  or 
whooping-cough,  is  much  higher  than  when  it  occurs  singly,  as  also 
is  that  of  measles  following  scarlet  fever ;  and  so  on.  If  measles 
or  scarlet  fever  attack  a  person  already  the  subject  of  any  tuber- 
culous lesion,  not  only  is  the  latter  apt  to  be  aggravated,  but 
complications  due  to  the  former  diseases  are  the  more  likely  to 
arise.  Beyond,  however,  this  intensification  of  severity,  concurrent 
infectious  diseases  do  not  appear  to  influence  one  another's  course. 
From  all  that  has  been  said,  it  is  quite  clear  that  one  infectious 
disorder  does  not  protect  against  another,  a  fact  which  may  be 
used  as  an  argument  in  favour  of  the  opinion  that  vaccinia  is 
essentially  the  same  as  smallpox.  If  not,  then  the  antagonism  of 
vaccinia  and  smallpox  forms  a  striking  exception  to  the  general 
rule. 

So  far  we  have  dealt  with  diseases  of  which  the  symptoms  are 
well  defined,  and  whose  distinct  entity  has  been  known  for  long 
periods,  in  some  instances  for  centuries.  But  bacteriology  has 
shown  us  that  certain  forms  of  disease,  hitherto  included  under 
such  general  terms  as  pyaemia  and  septicccmia,  are  due  to  the 
action  of  certain  pathogenic  micro-organisms  ;  and  it  has  further 
demonstrated  that  many  of  the  morbid  processes  associated  with 
diseases,  whether  specific  or  not,  are  due  to  the  secondary  invasion 
of  the  tissues  or  fluids  of  the  body  by  these  micro-organisms.  As 
an  example,  we  may  refer  to  measles.      One  of  the  most  common 


COINCIDENT  OR  MIXED  INFECTIONS  401 

and  fatal  complications  of  this  disease  is  broncho-pneumonia. 
There  is  good  evidence,  both  bacteriological  and  clinical,  to  show 
that  this  affection  is  not  due  to  the  essential  cause  of  measles. 
The  infective  agent  of  measles  appears  to  set  up  catarrh  of  the 
respiratory  tract,  and  thus  to  weaken  its  resistance  to  the  action 
of  such  organisms  as  the  pneumococcus  and  certain  strepto-  and 
staphylo-cocci.  In  a  case  of  measles,  therefore,  complicated  with 
broncho -pneumonia,  we  have  an  example  of  a  mixed  infection. 
Some  of  the  complicated  cases  of  scarlet  fever,  enteric  fever,  and 
diphtheria,  furnish  us  with  similar  illustrations.  Probably  further 
investigation  will  prove  this  principle  to  be  of  very  wide  application. 
There  is  reason  to  believe  that  the  various  organisms  of  which  we 
have  been  speaking  may  lead  a  saprophytic  existence,  and  that  it 
is  only  under  certain  circumstances  that  they  become  pathogenetic. 
This  is  true  of  so  specific  and  malignant  an  organism  as  the 
diphtheria  bacillus.  It  may,  therefore,  be  suggested  that  these 
organisms  have  their  seasonal  variations  of  prevalence  and  virulence 
in  much  the  same  way  as  do  such  primary  infections  as  smallpox, 
scarlet  fever,  and  diphtheria  ;  and  that  the  difference  in  type  of 
the  latter  (primary)  is  due  largely  to  the  variations  in  type  of  the 
former  (secondary)  infections. 

The  concurrence  of  two  or  more  infectious  diseases  in  the  same 
patient  is  a  frequent  source  of  difficulty  in  diagnosis.  It  would, 
in  fact,  be  quite  impossible  to  detect  some  combinations,  such  as 
rubella  co-existing  with  measles.  But  a  careful  attention  to  the 
individual  symptoms  of  each  separate  disease  will  often  assist  the 
avoidance  of  error. 

The  only  point  worthy  of  mention  here  with  respect  to  treatment 
is  the  necessity  of  providing  in  hospitals  for  infectious  diseases  a 
sufficient  number  of  separate  rooms  or  wards  for  the  isolation  of  such 
cases  of  mixed  or  coincident  infections  as  are  sure  to  occur. 

E.  W.  GOODALL. 


VOL.  I  2  D 


402  MANUAL  OF  MEDICINE 


DYSENTERY 

Although  the  word  "dysentery"  serves  to  designate  a  disease 
possessing  fairly  well-defined  clinical  and  anatomical  characteristics, 
it  is  possible,  nay  probable,  that  several  ailments  which  ought  to  rank 
separately  are  associated  under  the  term.  Of  these,  dysentery  ascribed 
to  hepatic  derangement,  to  malarial  infection,  to  scorbutus,  to  bad 
food,  impure  water,  or  other  sanitary  defect,  to  the  presence  of  the 
amoeba  coli,  and  to  other  micro-organisms  in  the  intestines,  are  a 
few  of  the  varieties  commonly  enumerated.  The  catarrhal  form 
of  the  disease  met  with  in  colder  climates,  and  the  dysentery  met 
with  in  the  tropics  in  an  endemic  form,  illustrate  further  the  wide 
divergence  of  types  which  obtain.  Of  these,  however,  the  only 
variety  which  approaches  scientific  precision  is  the  so-called  "amoebic 
dysentery."  That  the  amoeba  coli  is  met  with  frequently,  but  by  no 
means  invariably,  in  dysenteric  stools  is  undoubted  ;  that  it  is  met 
with  in  every  case  during  certain  epidemics  may  be  also  true,  and 
yet  its  presence  may  in  no  sense  bear  the  pathological  significance 
claimed  for  it  by  many  writers.  With  this  equivocal  exception, 
therefore,  no  scientific  division  of  the  group  of  diseases,  beUeved  to 
be  covered  by  the  name  "  dysentery,"  as  determined  by  their 
parasitology,  etiology,  or  pathology,  has  been  as  yet  arrived  at. 

Acute  dysentery  is  characterised  by  an  intestinal  flux,  consist- 
ing, at  the  commencement  of  the  illness,  of  loose  foeculent  matter 
mixed  with  blood  and  mucus.  The  foeculence  speedily  disappears, 
and  the  stools  present  a  flocculent,  slimy,  jelly-like  substance,  mixed 
with  blood.  In  aggravated  forms  of  the  disease  the  mucous  and 
submucous  coats  of  the  intestine  undergo  necrosis,  when  the 
evacuation  yields  a  putrid  .odour  and  contains  gangrenous  sloughs 
floating  in  a  thin,  brownish,  blood -tinged  liquid.  The  flux  is 
accompanied  by  febrile  disturbance,  by  acute  abdominal  pains,  by 
tenesmus,  and  by  nervous  and  physical  prostration.  Dysentery 
may  end  in  resolution  and  complete  recovery,  in  permanent 
damage  to  the  gut  (chronic  dysentery),  in  causing  liver  abscess,  in 
gradually  advancing  asthenia,  or  in  death  so  speedy  that  the  term 
"■  malignant  "  is  applied  to  it. 

Etiology. — That  several  varieties  of  dysentery  possess  a  specific 
cause  is  the  present-day  belief,  although  little  or  no  direct  evidence 
can  be  said  to  justify  the  conclusion ;  malaria  is  held  to  be  a  cause 


DYSENTERY  403 

of  dysentery,  because  dysentery  prevails  endemically  in  malarial 
countries,  because  the  febrile  disturbance  accompanying  the  disease 
resembles  malarial  fever,  but  more  directly  still  because  some  cases 
of  dysentery  are  "  cured  "  by  quinine.  The  frequent  association 
of  malarial  infection  with  dysentery  must  never  be  lost  sight  of; 
many  hold  the  opinion  that  malaria  is  the  principal  determining 
factor  in  the  etiology  of  the  disease,  and  it  is  well-nigh  imperative, 
before  proceeding  to  treat  a  case  of  dysentery,  that  the  blood  be 
carefully  examined  for  malarial  parasites.  Malaria,  whether  as  a 
cause,  a  complication,  or  a  sequela,  is  so  intimately  associated  with 
dysentery  that  quinine  must  not  be  altogether  neglected  in  the 
treatment  of  the  disease. 

Scurvy,  if  not  an  etiological  factor,  is  not  unfrequently  a  con- 
comitant ailment  in  dysentery.  In  simple  scurvy  the  bowels  are 
usually  constipated,  but  as  lowering  of  the  vitality  is  apt,  under 
certain  conditions,  to  invite  a  scorbutic  condition,  so  in  dysentery 
of  some  standing,  when  the  patient  is  unable  to  consume  anti- 
scorbutic nourishment,  scurvy  may  supervene.  The  appearance 
of  the  symptoms  of  scurvy  in  the  course  of  an  attack  of  dysentery 
will  determine  the  line  of  treatment  to  be  adopted. 

In  climates  such  as  the  Soudan,  in  which  there  is  a  marked 
difference  between  the  night  and  day  temperatures,  chill  is  a  potent 
factor  in  causing  dysentery.  During  a  military  campaign,  be  it  in 
India,  Southern  Europe,  or  the  United  States,  when  the  troops  are 
insufficiently  protected  from  the  cold  of  the  night,  dysentery 
develops  with  a  rapidity  and  certainty  which  can  only  be  put  down 
as  cause  and  effect.  Whether  it  is  the  liver  and  consequently  the 
portal  circulation  which  is  primarily  affected  by  the  cold,  or 
whether  it  is  the  direct  action  of  cold  on  the  intestines  themselves, 
is  not  known  ;  possibly  both  viscera  directly  suffer. 

Dysentery  is  also  enumerated  as  one  of  the  water-borne  diseases, 
and  certainly  in  those  towns  in  which  an  improved  water-supply 
has  been  obtained,  dysentery  has  abated  in  virulence,  and  in  the 
extent  of  its  prevalence.  On  board  ship  confirmatory  evidence  as 
to  the  pollution  of  the  water-supply  being  a  direct  cause  of  dysentery 
is  plentiful.  The  possibility  of  direct  infection  by  the  use  of  a 
common  latrine  must  not  be  lost  sight  of,  whether  the  virus  is 
considered  to  enter  by  the  anus,  the  mouth,  or  the  nostrils.  Any 
condition  which  tends  to  lower  the  strength  or  derange  the  health 
of  the  individual  during  the  prevalence  of  dysentery,  especially  in 
an  epidemic  form,  is  calculated  to  reduce  the  powers  of  resisting 
the  toxic  agency  of  the  disease. 


404  MANUAL  OF  MEDICINE 

Parasitology. — In  1875  Losch  described  a  protoplasmic 
parasite,  the  ama'ba  coli,  as  occurring  in  the  stools  of  dysenteries 
in  Russia,  and  since  then  the  amoeba  has  been  found  by  observers 
in  many  countries.  The  writer  met  with  the  amoeba  in  nine  con- 
secutive cases  of  dysentery  in  Hong-Kong;  in  three  cases  of 
malignant  dysentery,  however,  he  failed  to  find  it ;  and  others 
record  a  similar  experience.  When  a  small  fleck  of  the  flocculent 
mucus  of  a  dysenteric  stool  is  placed  on  a  warm  (100°  F.)  micro- 
scope stage,  immediately  after  being  passed,  the  presence  of  the 
amoeba  coli  may  be  recognised.  Its  large  size  (6  to  35  /x),  its 
mobility,  its  pale-greenish  colour,  and  its  strongly  refractive  powers, 
arrest  the  attention.  The  mobility  is  in  most  cases,  though  not  in  all, 
very  marked.  Pseudopodia  are  extruded  from  the  circumference, 
and  then  withdrawn  to  again  appear  at  another  part  of  the  mass. 
The  amoeba  is  not  only  altered  in  shape  by  the  pseudopodia,  but  the 
mass  changes  its  place,  travelling  either  towards  the  point  of  least 
resistance,  or  in  the  direction  of  alimentation.  Cold  (75°  F.)  and 
heat  (110°  F.)  arrest  the  movements  which,  under  favourable 
circumstances,  might  continue  for  a  couple  of  hours  or  more.  At 
rest,  the  body  of  the  amoeba  coli  is  seen  to  consist  of  a  thin,  pale- 
greenish,  outer  covering  or  ectoplasm,  and  an  inner,  granular, 
darker  endoplasm.  A  nucleus  is  present,  and  in  stained  specimens 
a  nucleolus.  The  amoeba  may  engulf  red  corpuscles,  micrococci, 
bacilli,  and  more  rarely  leucocytes  and  pigment.  Vacuoles  are 
a  fairly  constant  phenomenon.  The  arguments  for  and  against 
the  amoeba  coli  being  the  cause  of  dysentery  are — (i)  That  many 
observers  have  found  it  in  scores,  in  one  case  in  hundreds,  of  well- 
nigh  consecutive  cases.  (2)  That  the  injection  of  material  con- 
taining active  amoebfe  into  the  rectum  of  several  varieties  of 
animals  has  been  productive  of  dysenteric  symptoms.  (3)  The 
amoeba  coli,  however,  is  met  with  in  health,  with  or  without  the 
exhibition  of  a  severe  purge,  and  it  is  possibly  a  constant  occupant 
of  the  cgecum  and  upper  part  of  the  large  intestine. 

Dysentery  has  also  been  ascribed  to  other  micro-organisms, 
some  of  them  normal  inhabitants  of  the  intestines,  such  as  the 
bacterium  coli  commune,  which  is  accredited  by  some  with  taking 
on  special  pathological  properties.  Others  refer  dysentery  and 
liver  abscess  to  streptococci,  and  on  quite  inconclusive  grounds 
other  toxin-producing  micro-organisms  have  been  regarded  as  the 
cause  of  the  disease. 

The  difficulty  of  framing  an  accurate  definition  of  dysentery,  or 
a  satisfactory  conception  of  its  pathology,  due  to  the  uncertainty 


DYSENTERY  405 

both  as  regards  the  nature  of  the  specific  cause  of  the  disease  and 
of  the  real  value  to  be  attributed  to  the  several  conditions  which 
experience  shows  are  so  frequently  associated  with  its  occurrence, 
is  further  complicated  by  the  variety  in  its  clinical  course  and  features 
which  is  to  be  observed  in  various  epidemics  and  in  different  locali- 
ties. "  These  and  other  circumstances  seem  to  point  to  radical 
differences  in  the  several  forms  —  differences  of  cause  as  well  as 
differences  of  symptoms,  course,  and  sequelae.  It  is  well,  therefore, 
to  regard  the  term  '  dysentery  '  as  but  the  name  of  a  symptom,  or 
group  of  symptoms,  indicating  an  inflamed  condition  of  the  colon, 
and  not  as  indicating  a  single  and  well-defined  disease.  Dysentery 
simply  means  inflammation  of  the  colon.  There  may  be  many 
kinds  of  inflammation  of  the  colon  "  (Manson). 

Greographical  distribution. — Leaving  the  epidemic  dysen- 
teries of  colder  climates  out  of  the  question,  dysentery  increases 
in  frequency  as  the  Equator  is  approached.  Dysentery  is  endemic 
in  many  tropical  localities,  but  may  spread  thence  in  an  epidemic 
form  to  adjacent  countries.  It  may  be  safely  stated  that  in  those 
countries  in  which  a  real  improvement  in  sanitation  has  taken 
place,  dysentery  has  well-nigh  disappeared. 

Symptoms. — A  typical  case  of  acute  dysentery,  as  met  with 
in  practice  in  the  tropics,  is  characterised  by  the  following  signs 
and  symptoms  :- — During  what  appears  to  be  a  simple  intestinal 
catarrh,  or  commencing  suddenly,  shreds  of  mucus  appear  in  the 
evacuations ;  the  stools  become  more  frequent,  and  are  attended 
by  some  sweating  and  a  feeling  of  abdominal  weakness  after  being 
passed.  Blood  tinges  the  mucus,  or  is  in  sufficient  quantity  to  stain 
the  whole  fluid  of  the  stool.  Gripings  (tormina),  tenesmus,  and  an 
increasing  desire  to  pass  a  motion  supervene,  and  the  patient's  calls 
for  the  bed-pan  become  almost  incessant.  All  trace  of  foeculence 
disappears,  and  at  an  evacuation  a  tablespoonful  of  blood-stained, 
foul-smelling,  jelly-like  material,  attended  by  great  straining,  may 
be  all  that  is  passed.  The  tongue  becomes  coated  and  furred,  the 
mouth  is  clammy,  the  saliva  tenacious,  a  feeling  of  nausea  fre- 
quently occurs  during  the  early  stools,  but  vomiting  is  rare.  The 
abdomen  is  tender,  especially  over  the  lower  part  of  the  colon  in 
the  left  iliac  fossa,  the  anus  is  excoriated,  hot  and  burning,  and 
the  bowel  may  be  prolapsed.  Movement  causes  palpitation,  and 
the  pulse  becomes  small  and  frequent.  Urine  is  scanty,  high 
coloured,  and  occasionally  suppressed ;  strangury  and  retention 
are  also  possible  complications.  Increase  in  temperature  is  con- 
stant, but,  except  in  the  malignant  form,  the  thermometer  seldom 


4o6  MANUAL  OF   MEDICINE 

registers  more  than  ioi°  or  102^.  In  the  acute  form  dysentery 
may  continue  several  days,  or  in  young  strong  men  for  as  many  as 
twenty  or  more  days,  and  yet  the  patient  may  make  a  good  and 
permanent  recovery.  Frequently,  however,  if  signs  of  abatement 
do  not  appear  towards  the  end  of  the  first  week  or  earlier,  the 
disease  assumes  a  type  which  betokens  danger  to  Hfe.  The  stools 
may  contain  shreds  and  sloughs  floating  in  a  fluid  of  dark-brown 
hue  and  smelling  abominably.  The  tongue  looks  red  and  glazed, 
or  is  coated  by  a  brown  fur ;  sordes  cover  the  teeth,  the  abdomen 
becomes  tympanitic  and  tender,  and  haemorrhage  may  occur  from 
the  bowel,  or  from  the  mouth  and  nose.  The  temperature  rises  to, 
and  continues  at,  104°  or  higher;  the  pulse  at  the  wrist  is  small, 
feeble,  extremely  rapid,  and  frequently  irregular.  Hiccough  may 
become  persistent,  and  the  patient,  after  passing  through  a  low, 
nervous  state,  during  which  all  painful  sensations  abate  or  cease, 
dies  in  a  state  of  coma. 

The  disease  may  end  in  one  of  three  ways : — In  convalesence 
and  complete  recovery ;  in  chronic  dysentery,  with  permanent 
damage  to  the  intestinal  wall ;  or  in  death  from  collapse,  from 
haemorrhage,  from  peritonitis  caused  occasionally  by  perforation, 
from  exhaustion,  or  after  passing  through  a  typhoid  state.  Sudden 
death,  attributed  to  heart  failure,  may  occur  during  convalescence, 
even  when  the  stools  are  assuming  a  natural  consistence. 

Varieties. — Acute  dysentery  receives  a  variety  of  names  according 
to  the  assumed  cause,  and  the  signs  and  symptoms  that  predominate. 
Most  of  these  names,  coined  from  mere  clinical  variations,  are 
counterfeit,  and  but  add  to  the  chaos  of  nomenclature.  Malarial 
dysentery  presents  few  specific  clinical  phenomena.  Apart  from 
the  history,  the  presence  of  the  malarial  parasite  in  the  blood,  and 
the  variations  in  the  temperature  of  the  body,  the  most  marked 
symptoms  are  a  tendency  to  early  prostration  and  algidity,  and  the 
loss  of  a  large  quantity  of  blood  by  the  bowel.  The  curative  effect 
of  quinine,  however,  has  done  most  to  stamp  this  variety  of  dysen- 
tery as  malarial.  The  so-called  ptirulent,  gangrenous,  and  fibriiioiis 
or  pseudo-diphtheritic  varieties  are  all  preceded  by,  and  are  but  the 
natural  sequelae  of  an  unchecked,  simple,  or  catarrhal  dysentery. 
The  continuance  of  the  specific  irritation  of  the  bowel  may  lead  to 
the  infiltration  of  its  walls  with  fibrinous  material  or  with  pus,  to 
the  formation  of  ulcers,  and,  when  the  infection  is  still  more 
virulent,  to  obstruction  of  the  blood  vessels  and  sloughing  of  the 
mucous  and  submucous  coats  of  the  bowel.  When  the  wall  be- 
comes   extensively    infiltrated    with    a    fibrinous    deposit,    the    gut 


DYSENTERY  407 

becomes  somewhat  rigid,  the  calibre  variable,  wide  in  parts  and 
narrow  in  others,  and  an  incision  into  its  tissue  betrays  a  rather 
tough  semi-cartilaginous  consistence.  The  names  scorbutic  dysentery 
and  typJioidal  dysentery  indicate  either  the  association  of  an  intes- 
tinal flux  resembling  dysentery  occurring  during  an  attack  of  scurvy, 
typhus,  or  typhoid,  or,  that  a  dysenteric  attack  assumes,  during 
its  course,  features  peculiar  to  either  scurvy,  typhus,  or  typhoid. 
Hepatic  dysentery  is  a  convenient  term  whereby  the  early  implica- 
tion of  the  liver  in  the  dysenteric  attack  is  prominently  noted.  On 
the  one  hand  the  condition  of  the  liver  may  be  a  primary  etiological 
factor  or,  on  the  other  hand,  the  liver  may  be  infected  during  ihe 
course  of  the  disease  in  the  bowel  by  way  of  the  portal  vein.  When 
vomiting  is  prevalent,  the  liver  enlarged  and  tender,  and  considerable 
pain  in  the  right  hypochondrium  supervenes  during  an  attack  of 
dysentery,  it  is  usual  to  stamp  the  variety  as  hepatic.  The  dysentery 
of  war  and  fafiiine  occurs  independently  of  climate  and  season;  it 
is  an  extremely  fatal  form,  and  there  seems  little  doubt  it  is  con- 
tagious. So-called  atncebic  dysentery  is  stated  to  exhibit  marked 
chronicity,  frequent  relapses,  and  a  pronounced  tendency  to  cause 
liver  abscess.  In  the  stools  the  amoeba  coli  is  necessarily  present, 
but  none  of  the  signs  or  symptoms  are  sufficiently  constant  to 
define  the  amoebic  form  as  a  specific  clinical  variety. 

Chronic  dysentery. — The  acute  form  of  the  disease  frequently 
results  in  a  chronic  dysenter)'.  After  the  acute  symptoms  have 
subsided,  and  stools  possessing  fceculence  and  some  consistency  are 
passed,  instead  of  complete  recoveiy  following,  the  mucous  flux  may 
persist,  pain  of  a  subacute  character  remains,  and  the  general  health 
of  the  patient  does  not  improve  satisfactorily.  As  time  passes  the 
stools  may  become  fairly  well  formed  or  constipated,  and  yet  jelly- 
like or  muco  -  purulent  matter,  and  occasionally  blood,  accom- 
pany them.  This  fluid  material,  as  a  rule,  precedes  the  stool, 
showing  that  the  seat  of  the  trouble  is  just  within  the  anus. 
Haemorrhoids,  and  painful  ulcer  of  the  rectum,  are  frequently 
associated  with  or  mistaken  for  dysentery,  and  it  is  at  times  difficult 
to  ascertain  the  origin  of  the  trouble.  Pressure  in  the  left  iliac 
fossa  over  the  sigmoid  flexure,  and  sometimes  in  the  right  iliac 
fossa  over  the  csecum,  elicits  pain ;  and  the  sigmoid  flexure  may  be 
felt  to  be  indurated,  enlarged,  and  tender.  The  stools  are  irregular 
as  to  the  time  of  their  being  passed  as  well  as  in  the  character  of 
their  consistence.  Exposure,  fatigue,  and  inadvertence  in  diet  may 
induce  a  semi-acute  attack,  causing  an  aggravation  of  the  diseased 
state.     This  may  continue  until  a  chronic  state  is  established,  the 


4oa  MANUAL  OF  MEDICINE 

bowel  being  so  altered  that  the  ulcerated  surfaces  become  incapable 
of  healing,  or,  should  they  do  so,  pronounced  cicatrices  and 
narrowing  of  the  gut  ensue.  In  chronic  dysentery  the  tongue  may 
become  red,  raw,  and  fissured,  the  appetite  at  times  may  be 
voracious,  and  at  others  in  abeyance  ;  the  stools  retain  some  of  their 
disagreeable  odour,  and  in  some  cases  are  of  unusual  bulk,  and 
seemingly  fermenting.  The  patient's  health  suffers ;  he  becomes 
sallow,  emaciated,  cachectic,  and  in  the  gravest  cases  hectic  appears, 
attended  by  anaemia  and  sweatings ;  a  fatal  issue  is  then  at  hand, 
and  death  results  either  from  gradual  exhaustion,  or  from  some 
concomitant  ailment,  with  dropsy,  pneumonia,  or  cardiac  failure. 

Dysentery  afid  liver  abscess. — The  relation  between  dysentery  and 
liver  abscess  is  an  important  one  clinically  and  pathologically. 
Many  observers  believe  that  in  almost  all,  if  not  in  all,  cases  of  liver 
abscess,  a  previous  historj'  of  dysentery  can  be  elicited ;  whilst,  on 
the  other  hand,  a  few  attempt  to  disassociate  the  ailments. 
Analogy,  however,  favours  the  conclusion  that  the  two  are  associated, 
as  in  most  ulcerative  and  inflammator)'  lesions  of  the  intestine,  other 
than  dysenteric,  there  is  a  marked  tendency  to  the  deposit  of  in- 
fective and  purulent  matter  in  the  liver  substance.  Clinical  ex- 
perience shows  that  liver  abscesses  were  found  by  Woodward  in  2 1 
per  cent  of  autopsies  on  patients  dying  of  dysenteiy;  and  in  as  many 
as  60  per  cent  of  cases  of  liver  abscess  a  history  of  dysentery  was 
elicited  by  Kartulis  in  Egypt.  Many  circumstances,  however,  pro- 
nounce against  the  conclusion  that  dysentery  is  an  invariable  ante- 
cedent of  abscess.  None  more  so  perhaps  than  the  fact  that  although 
dysentery  is  very  prevalent  amongst  natives,  abscess  of  the  liver  is 
rarely  met  with.  The  whole  question,  however,  turns  upon  the 
question  whether  there  are  not  several  varieties  of  liver  abscess.  In 
the  majority  of  intra-hepatic  abscesses  no  doubt  dysenter}'  is  the 
primary  factor,  but  in  those  abscesses  which  form  not  in.,  but  upon 
the  liver,  and  most  frequently  between  the  layers  of  the  broad  liga- 
ment of  the  hver,  it  is  difficult  to  explain  a  positive  connection. 
Although  the  presence  of  the  amoeba  coli  in  the  intestines  and  in 
liver  pus  would  seem  to  point  to  a  relationship  of  cause  and  effect,  it 
must  be  noted  that  the  parasite  is  not  usually  found  in  pus  issuing 
from  a  liver  abscess  until  the  third  or  fourth  day  after  the  abscess 
has  been  opened  or  tapped.  Not  only  so,  but  liver  pus  is  peculiar 
in  that  it  is  frequently  "  sterile  "  when  first  drawn  off,  none  of  the 
usual  purulent  organisms  being  demonstrable. 

In  a  paper  read  at  the  annual  meeting  of  the  British  Medical 
Associationj   1899  {Brit,  Med.  Journ.   9th  Sept.    1899),  the  writer 


DYSENTERY  409 

divided  liver  abscesses  into  two  varieties,  suprahepatic  and  intra- 
hepatic. The  latter  is  the  result  of  dysentery ;  the  pus  shows  the 
usual  purulent  organisms,  streptococci,  etc.,  and  the  amoeba  coli  is 
perhaps  present  from  the  first.  The  suprahepatic  abscess  is  non- 
dysenteric  in  origin,  the  pus  is  sterile  and  the  amoeba  coli  does  not 
appear  in  the  pus  until  after  the  third  day  of  drainage.  The  pus 
from  an  intrahepatic  abscess  tends  to  reach  the  surface  by  way  of 
the  abdominal  wall,  but  may  burst  into  the  peritoneum,  the  stomach 
or  duodenum,  the  ilio-lumbar  region,  the  bile  duct,  the  vena  cava, 
or  even  into  the  kidney.  Suprahepatic  pus  tends  towards  the 
thorax,  and,  pointing  upwards  through  the  diaphragm,  may  reach 
a  bronchus,  when  it  is  expectorated  or  may  find  its  way  into  the 
cavity  of  the  pleura  or  pericardium. 

Post-mortem  appearances. — In  the  simple  forms  of  acute 
dysentery,  although  the  opportunities  of  study  are  necessarily  limited, 
the  conditions  are  primarily  similar  to  those  met  with  in  acute 
colitis  and  enteritis.  In  rapidly  fatal  cases  of  the  gangrenous  or 
malignant  type,  however,  the  lesions  are  unfortunately  more  fre- 
quently seen.  The  changes  in  the  bowel  in  the  latter  form  are 
destruction  of  extensive  areas  of  the  mucous  and  submucous  coats 
of  the  large  and  occasionally  of  the  small  intestine ;  ulcers  of  all 
sizes  with  undermined  edges,  and  frequently  with  sinuses  com- 
municating between  neighbouring  ulcers,  exist  in  large  numbers. 
The  ulcers  in  the  wall  of  the  gut  frequently  coalesce,  and  a  ragged, 
uneven,  patchy  surface  may  extend  the  entire  length  of  the  colon. 
In  the  swollen  mucosa  small  abscesses,  varying  in  size  from  a  pin's 
head  to  a  pea,  stud  the  tissue.  When  cut  into  they  are  seen  to  be 
closed  sacs  containing  a  tenacious  pus,  but  the  apices  of  others  may 
be  found  open,  emitting  pus  when  squeezed,  and  it  is  possible,  nay 
probable,  that  the  formation  and  bursting  of  these  abscesses  is  but 
the  initial  stage  of  the  ulcerative  process.  What  remains  of  the 
inner  coats  of  the  intestine  appears  swollen,  raised  and  injected,  or 
here  pale  and  there  red  and  congested.  The  floors  of  the  ulcers 
present  an  ashen-gray  colour,  where  the  sloughs  have  been  detached, 
or  the  muscular  coat  may  even  be  exposed  to  view.  The  lesion  is 
usually  most  marked  in  the  rectum,  sigmoid  flexure,  and  descend- 
ing colon,  but  the  disease  may  involve  the  whole  of  the  large  gut, 
the  caecum  becoming  the  seat  of  advanced  ulceration  and  sloughing. 
The  disease  may  also  spread  through  the  ileo-csecal  valve  and  in- 
volve the  small  intestine  to  the  extent  of  a  foot  or  two.  Although 
in  dysentery  the  gut  is  so  deeply  ulcerated  that  a  mere  transparent 
film  of  tissue  remains,  perforation  is  rare.     Frequently  a  protective 


4IO  MANUAL   OF   MEDICINE 

local  peritonitis  bars  the  way  to  extravasation  of  the  intestinal 
contents.  Everything  points  to  the  rectum  being  the  primary  seat 
of  the  disease ;  so  markedly  is  this  the  case,  that  it  would  seem  in 
fact  as  though  the  infective  process  started  from  the  anus,  and 
several  observers  are  of  this  belief  Many  believe  that  defecation 
over  a  freshly  passed  dysenteric  or  choleraic  stool  is  a  source  of 
direct  infection  by  way  of  the  bowel  in  these  respective  diseases, 
and  there  seems  some  evidence  in  favour  of  the  assumption. 

In  chronic  dysentery  the  gut  presents  very  diverse  conditions. 
The  colour  of  the  mucous  surface  becomes  for  the  most  part  much 
darker,  and  in  parts  brownish  black.  Old  irregular  cicatrices  of 
healed  ulcers  are  everywhere  met  with  between  the  elevated, 
thickened,  and  indurated  mucous  ridges.  The  whole  wall  of  the 
bowel  is  in  parts  hypertrophied  and  the  lumen  narrowed,  in  parts 
thinned  and  atrophied,  as  if  a  mere  touch  would  cause  rupture. 
Recent  abscesses  may  be  present,  and  sinuses  may  be  found  passing 
beneath  bridges  of  cicatricial  bands  and  constrictions.  The  mucous 
and  glandular  structures  are  never  reproduced  when  once  destroyed. 
In  consequence  of  these  conditions,  dilatations  and  contractions  of 
the  calibre  of  the  intestine  are  frequently  seen. 

The  liver  in  acute  dysentery  is  congested  and  enlarged,  and 
with  single  or  multiple  intrahepatic  abscesses.  In  chronic  dysentery 
the  liver  is  more  frequently  met  with  of  reduced  size ;  but  owing 
to  subacute  attacks  of  dysentery  supervening,  the  liver  may  be 
deeply  congested,  or  become  the  seat  of  abscess. 

The  spleen  varies  in  size  and  consistence ;  in  acute  dysentery 
it  is  usually  full,  soft,  and  deeply  congested,  whereas  in  the  chronic 
form  of  the  disease  it  is  either  considerably  and  permanently 
enlarged  or  markedly  diminished  in  bulk. 

Towards  the  end  of  a  fatal  case,  the  lungs  and  kidneys  may 
become  involved,  but  these  viscera  are  not  primarily  affected  during 
dysentery. 

Diagnosis. — The  signs  and  symptoms  stamp  dysenter}',  in  the 
sense  of  a  dysenteric  flux,  decisively ;  but  the  variety  of  the  disease 
under  treatment  may  be  difficult  to  decide  upon.  It  is  frequently 
by  a  process  of  exclusion  during  the  progress  of  a  case  that  one 
decides  whether  the  dysenter}-  is  of  the  hepatic,  the  amoebic,  the 
scorbutic  or  of  the  malarial  variety,  and  this  information  may  be 
gathered  solely  by  the  effects  of  treatment  upon  the  disease.  Chronic 
dysentery  is  diagnosed  chiefly  by  the  history  of  the  case,  but  in  part 
also  by  the  nature  of  the  stools.  Several  affections  may  set  up  a 
condition  allied  in  symptoms  to  dysentery.     A  fibrous  stricture  of 


DYSENTERY  411 

the  rectum,  malignant  or  syphilitic,  especially  in  old  tropical  residents, 
may  either  mask,  or  be  masked  by,  dysentery.  Proctitis,  painful 
ulcer  of  the  rectum,  the  diarrhcea  of  Sprue,  or  in  fact  any  intestinal 
flux  may  complicate,  or  be  mistaken  for  chronic  dysenterj'.  In 
certain  tropical  countries  the  presence  of  the  round  worm  or  of 
other  intestinal  parasites  may  produce  a  foecal  irregularity  which 
may  lead  to  mistakes  in  diagnosis  and  consequent  errors  in  treat- 
ment. 

Although,  however,  the  term  dysenter}'  is  regarded  as  a  con- 
venient name  for,  it  may  be,  a  number  of  ailments  arising  from  in- 
dependent causes,  there  are  a  number  of  signs  and  symptoms  which 
determine  its  presence;  of  these  the  chief  are:  general  abdominal 
tenderness,  tormina  immediately  before,  and  tenesmus  during  and 
after  a  motion  ;  the  stools  consist  of  mucoid  material  tinged  with 
blood,  but  if  the  disease  persists,  they  contain  a  bloody  slime, 
gelatinoid  particles,  and,  in  advanced  cases,  gangrenous  sloughs 
smelling  abominably.  An  increase  in  temperature,  intense  thirst, 
a  furred  tongue  and  rapid  loss  of  strength  ser\-e,  with  the  above 
abdominal  symptoms,  to  stamp  the  disease  as  dysenteric.  Ulcera- 
tive colitis  is  the  name  assigned  to  a  condition  of  the  bowel  which, 
in  pathological  and  in  many  clinical  features,  resembles  dysentery. 
Colitis,  however,  occurs  in  temperate  climates  and  in  persons  who 
have  never  visited  the  tropics ;  moreover,  the  tenesmus,  the  burn- 
ing pain  at  the  anus,  the  unceasing  desire  to  go  to  stool,  etc.,  so 
harassing  in  dysentery  are  not  met  with  in  ulcerative  colitis. 

In  all  cases  of  doubtful  nature,  a  digital  and  specular  examina- 
tion of  the  rectum  ought  to  be  made. 

Prognosis. — AVhen  the  malignant  characters  set  in  early  in  the 
disease,  there  is  but  little  hope  of  saving  the  patient ;  and  when  a 
chronic  dysenter}'  continues  for  a  year  or  two,  there  is  little  chance 
of  a  permanent  cure.  Simple  acute  dysenterj',  however,  is  not  in 
itself  a  fatal  disease,  the  only  sequela  likely  to  happen  being  a 
chronic  dysenter}'  of  some  duration  ;  at  any  moment,  however,  a 
simple  case  may  assume  a  malignant  type. 

Mortality.  —  The  death  -  rate  in  dysentery  varies  with  race, 
environment,  and  type  of  the  disease.  Natives  succumb  more 
readily  than  Europeans  in  the  tropics ;  the  former  show  a  case 
mortaUty  of  from  37  to  40  per  cent,  whilst  the  latter,  according  to 
Indian  statistics,  show  one  of  from  3  to  22  per  cent.  Emaronment 
plays  an  important  part  in  the  chances  of  recover)'.  A  European 
enjoying  good  sanitary  surroundings,  good  food,  and  scientific  treat- 
ment stands  a  much  better  chance  of  recovery  than  the  native  in 


412  MANUAL   OF   MEDICINE 

his  squalid  abode,  with  his  crude  medicines  and  indifferent  food. 
The  type  of  the  disease,  however,  largely  determines  the  mortality, 
malignant  dysentery  allowing  but  a  small  chance  of  recover)-,  for 
it  must  be  considered  one  of  the  most  fatal  ailments  known.  The 
danger  of  an  attack  of  dysentery,  however,  is  by  no  means  over 
when  the  acute  symptoms  have  subsided  ;  chronic  intestinal  troubles 
are  apt  to  be  set  up,  leading  to  contraction  and  obstruction  of  the 
intestine,  loss  of  power  of  assimilation  and  consequent  wasting, 
chronic  diarrhoea,  and  greater  vulnerability  to  attacks  of  intercurrent 
diseases. 

Treatment. — The  principles  of  treatment  of  acute  dysentery 
are  rest,  suitable  diet,  and  either  arrest  of  the  intestinal  flux  by 
appropriate  remedies  or  its  elimination  by  purgatives.  The  rest 
should  be  absolute  ;  the  patient  should  be  confined  to  bed,  and  the 
use  of  the  bed-pan  insisted  upon.  The  writer,  however,  goes 
further  than  merely  obtaining  general  rest,  and  recommends  the 
application  of  a  large,  thick,  firm  pad,  big  enough  to  cover  the  whole 
front  of  the  abdomen  ;  retaining  the  pad  by  a  broad,  tightly  applied 
binder  round  the  body.  Alternately  applied  wet  and  dry  pads,  or  a 
continuously  applied  wet  pad  increases  the  effectiveness  of  this 
device.  Rest  may  be  further  procured  by  morphia  hypodermically, 
or  by  opium  given  by  the  mouth  or  rectum  ;  the  plan  of  giving 
castor  oil  3iij,  with  20  minims  tincture  of  opium,  in  the  ver}-  early 
stages  of  dysenter}',  has  everything  to  recommend  it.  At  the  onset 
of  an  acute  attack  food  should  be  reduced  to  a  minimum.  Rice- 
tea  (rice,  browned  in  the  oven  and  infused  with  boiling  water),  or 
whey  are  to  be  given  in  sips,  and  ice  pellets  may  be  sucked  if  the 
thirst  is  intense.  Ordinary'  weak  tea,  without  milk  or  sugar,  is  a 
very  grateful  beverage  in  dysentery. 

When  dysentery  proves  intractable  to  these  simple  remedies, 
ipecacuanha  should  be  given.  The  formula  for  administration  is 
as  follows  : — Two  hours  before  the  time  selected  to  give  the 
drug  all  food  is  to  be  withheld,  and  only  small  pieces  of  ice  given 
to  suck.  Twenty  minutes  before  giving  the  ipecacuanha,  half  a  grain 
of  morphia  may  be  administered  hypodermically,  or  25  minims  of 
laudanum  is  to  be  exhibited  by  the  mouth.  Ten  minutes  before 
the  ipecacuanha  is  given,  place  a  mustard  leaf,  or  mustard  plaster 
the  size  of  the  hand,  on  the  epigastrium.  Give  30  grains  of  ipecacu- 
anha root  freshly  prepared,  in  pills,  cachets,  or  wafer  paper.  Five 
or  ten  minutes  after  the  administration,  remove  the  mustard  plaster. 
Insist  upon  the  patient  keeping  quiet  with  the  head  low,  and  give 
particles  of  ice  to  suck.      No  other  food  or  drink  is  allowed  until 


DYSENTERY 


413 


at  least  three  hours  afterwards,  when  sips  of  weak  tea  or  rice-tea  will 
be  found  to  be  most  beneficial.  The  continuance  of  the  ipecacu- 
anha treatment  will  depend  upon  the  character  of  the  stool.  One 
dose  may  bring  down  a  foeculant  stool,  but,  failing  improvement, 
the  drug  may  be  continued  twice  a  day  in  i  o-grain  doses  for  several 
consecutive  days. 

Malaria  may  be  either  a  cause  or  a  complication  of  dysentery, 
and,  should  ipecacuanha  fail,  quinine  is  indicated  in,  say,  5 -grain 
doses  every  six  hours  for  two  days.  In  pregnant  women  both 
ipecacuanha  and  quinine  may  be  given  if  opium  is  freely  administered 
at  the  same  time.  Scorbutus  is  not  unfrequently  the  genesis  of 
dysentery,  and  the  reputation  gained  by  several  "native"  remedies 
arises  no  doubt  from  their  efficacy  in  this  variety  of  the  disease. 
The  fresh  plants,  leaves,  or  fruit  supply  the  vegetable  acids  re- 
quired for  the  treatment  of  scurvy  in  whatever  form  it  may 
appear.  Simariiba  bark  is  much  in  vogue  in  the  southern 
countries  of  North  America.  It  is  exhibited  in  a  variety  of  ways  ; 
the  best,  perhaps,  is  in  the  form  of  infusion  obtained  by  boiling 
I  oz.  of  the  powdered  bark  in  3  pints  of  water  until  the  quantity 
is  reduced  to  half  the  bulk.  One-half  the  quantity  may  be  given 
morning  and  evening.  The  writer  has  experience  of  viangostine 
rmd  in  the  treatment  of  dysentery ;  and  in  the  Straits  Settlements 
and  throughout  Malaya  it  is  held  in  high  esteem.  It  is  best  pre- 
pared by  boiling  the  rinds  of  three  dried  mangostines  in  i|  pint 
of  water  until  the  quantity  is  reduced  to  i  pint.  One-third  of 
the  pint  is  given  thrice  daily.  The  Mofisonia  ovata  is  a  South 
African  plant  from  which  a  tincture  (i  in  8,  alcohol,  90  per  cent) 
is  made  and  administered  in  doses  of  i  to  4  drachms  every  four 
hours.  In  India  bael  fruit  is  extensively  used.  The  preparation 
must,  however,  be  made  from  the  fresh  fruit,  so  that  its  efficacy 
can,  like  many  other  native  remedies,  be  only  ensured  locally. 

The  aperient  treatment  may  be  tried  when  ipecacuanha,  quinine, 
etc.,  fail,  or  it  may  be  employed  from  the  onset.  There  are  two 
methods  of  administration  :  (a)  \  oz.  of  the  sulphate  of  sodium 
or  magnesium  dissolved  in  a  small  quantity  of  hot  water  may  be 
given  to  commence  with,  followed  by  smaller  doses  every  six  or 
eight  hours ;  (b)  or  60  grains  of  either  of  these  salts  may  be  given 
every  quarter  of  an  hour  or  every  half  hour  until  the  stools  show 
signs  of  foeculence.  When  drugs  fail,  the  writer  places  most  reliance 
on  an  ample  cold  (ice  cold  if  necessary)  wet  pack  applied  to  the 
whole  front  of  the  abdomen.  Pressure  is  maintained  by  a  bath 
towel   wrapped   tightly    round   the   body  from   mammse  to  groins. 


414  MANUAL   OF   MEDICINE 

Re-apply  the  wet  pack  every  two  hours,  and  persevere  with  the  treat- 
ment for  thirty-six  or  forty-eight  hours.  In  many  cases  this  plan 
of  treatment  well  deserves  the  title  "  specific."  The  treatment  by 
calomel  and  opium  is  worthy  of  trial  when  other  means  fail,  either 
with,  or  without,  ipecacuanha.  These  are  given  in  combination, 
in  doses  of  i  grain  of  each  every  six  hours. 

Although  the  stools  become  foeculent,  they  may  remain  quite 
loose,  and  this  diarrhoea  may  require  to  be  arrested  by  some  one 
of  the  many  astringents  in  use ;  bismuth  and  opium  usually  suffice, 
but  sulphate  of  copper,  of  zinc,  or  of  iron,  are  also  employed  for 
the  purpose. 

Attempts  at  disinfection  of  the  bowel  by  such  substances  as 
salol  in  gr.  20  doses,  by  creolin  (gr.  3),  by  napthalin  (gr.  5),  by  tar 
(gr.  5),  by  creasote  (min.  20),  and  a  host  of  other  drugs  have  been 
employed,  and  with  but  ephemeral  success.  Injections  also  of 
disinfectants  by  the  bowel  can  only  be  of  evanescent  value,  as  to 
keep  the  intestine  "sweet"  a  constant  stream  of  the  injection 
would  have  to  be  kept  up. 

In  malignant  dysentery,  when  sloughs  are  being  passed  and  the 
patient's  strength  is  becoming  rapidly  exhausted,  "  specific  "  drugs 
are  well-nigh  useless.  Instead,  every  form  of  rational  stimulant 
must  be  employed  to,  if  possible,  tide  the  patient  over  the  stage  of 
acute  depression.  In  this  variety  the  use  of  disinfectants  for  the 
intestine  is  theoretically  sound,  but  practically  the  plan  is  not  of 
much  value  owing  to  the  difficulty  of  its  application. 

When  dysentery  becomes  chro7iic,  the  use  of  drugs  is  dis- 
appointing. Ipecacuanha  loses  its  power,  and  it  would  seem  as 
though  the  ragged,  ulcerated,  and  congested  gut  demanded  local 
treatment.  A  copious  enema  of  plain  boiled  water  (allowed  to 
cool  to  100°  F.),  followed,  when  the  water  has  been  passed,  by  an 
injection  of  i  or  2  pints  of  boracic  acid  (saturated  solution)  or 
nitrate  of  silver  (\,  |,  or  i  grain  to  the  ounce  of  warm  distilled 
water)  are  efficient  remedies.  The  injection  ought  not  to  be 
forcibly  given  by  an  enema  syringe,  but  by  an  india-rubber  tube 
and  a  funnel  held  not  more  than  two  feet  above  the  level  of  the 
patient's  body  as  he  lies  in  bed.  The  astringent  injection  should 
be  retained  for  an  hour  if  possible.  After  many  trials  of  the  long 
tubi  for  the  bowel,  the  writer  has  discarded  it  as  unnecessary  and 
dangerous.  The  injected  fluid  finds  its  way  along  the  gut,  if 
introduced  slowly,  more  readily  by  syphonage  than  when  adminis- 
tered by  either  an  enema  syringe  or  by  a  long  tube. 

Of  the  many  drugs  and  methods  employed  in  the  treatment  of 


DYSENTERY  415 

chronic  dysentery,  the  writer  relies  on  rest  in  bed ;  cold  wet  packs 
twice  a  day,  morning  and  evening,  for  two  hours ;  an  occasional 
dose  of  castor  oil ;  subnitrate  of  bismuth  in  gr.  20  doses,  given 
in  combination  with  i  drachm  of  the  confection  of  black  pepper, 
and  washing  out  the  intestine  by  astringent  lotions.  In  the  consti- 
pation which  so  frequently  follows  dysentery,  cascara  in  moderate 
doses,  administered  daily  for  a  month  or  two,  is  an  effective 
remedy. 

Diet, — A  purely  milk  diet  is  the  usual  routine  of  treatment  in 
intestinal  flux,  whatever  is  the  cause.  The  milk  is  given  in  sips, 
or  in  very  small  quantities  repeated  frequently.  Some  prefer  the 
milk  warmed,  others  exhibit  it  with  ice.  In  the  acute  initial 
stages  of  the  disease,  however,  milk  does  not  seem  suitable,  and 
in  its  stead  rice  -  tea,  weak  chicken  broth,  whey,  ordinary  very 
weak  tea  (cold  or  warm),  barley  water,  or  koumiss  may  be 
given.  In  chronic  dysentery  the  writer  finds  the  treatment 
by  meat  and  "  meaty  substances "  the  most  eflScacious.  The 
patient  is  fed  thrice  daily  on  beef,  reduced  to  a  fine  mince, 
which,  after  being  very  lightly  cooked,  is  served  up  5  oz.  at  a 
time.  Nothing  but  salt,  and  maybe  the  white  of  an  egg,  is  given 
with  the  meal.  Between  meals  and  during  the  night  the  patient 
is  allowed  to  eat  calves'  foot  jelly  freely.  Hot  water  is  the  best 
drink,  taken  a  quarter  of  an  hour  before  or  half  an  hour  after  meals. 
If  the  patient  is  too  weak  to  take  beef  in  this  form,  he  may  be 
fed  on  teaspoonfuls  of  freshly-made  raw  meat  juice  every  ten 
minutes ;  scraped  raw  beef,  and  raw  meat  sandwiches  being  added 
as  the  strength  gains,  and  the  intervals  lengthened  as  the  power  of 
digestion  improves.  A  change  to  a  temperate  climate  is  an 
essential  element  in  the  treatment  of  Europeans  suffering  from 
dysentery  when  the  disease  threatens  to  become  chronic.  When 
hepatic  derangements  are  concomitant,  a  course  of  treatment  at 
a  medicinal  spa,  more  especially  that  of  Carlsbad,  is  highly  to 
be  recommended. 

James  Cantlie. 


4i6  MANUAL  OF  MEDICINE 


MALARIA  AND   MALARIAL  FEVERS 

A  group  of  specific  diseases,  characterised  by  fever  of  an 
intermittent,  continued,  or  remittent  type,  giving  rise  to  anaemia, 
with  pigmentary  deposits,  and  tissue  changes  in  the  spleen,  liver, 
and  other  organs.  The  parasites  occupy  and  destroy  the  red 
blood  corpuscles.  Certain  species  of  mosquitoes  and  possibly  other 
blood-sucking  insects  serve  as  intermediate  hosts  in  the  life  cycle  of 
the  parasites. 

Distribution. — While  yet  Western  Europe  and  the  Mediter- 
ranean littoral  were  the  only  countries  known  to  civilisation,  malarial 
diseases  were  almost  universally  distributed  within  them.  In  Eng- 
land, and  even  in  Scotland,  malaria  at  one  time  prevailed,  but  with 
better  drainage,  reclamation  of  swampy  lands  and  improved  sanita- 
tion generally,  malaria  has  receded  from  its  more  northerly  sphere. 

When  other  continents  became  known  to  European  travellers 
and  colonists,  it  was  found  that  no  country  north  of  the  Equator 
from  the  Arctic  circle  to  the  Tropics  was  free  from  malaria ;  but  as 
the  Tropics  were  approached,  however,  it  was  found  that  malarial 
disease  became  more  prevalent.  In  North  America  also  malaria  is 
gradually  receding  before  drainage  and  cultivation,  until  at  the 
present  time  it  is  seldom  met  with  north  of  the  45th  degree  of 
latitude.  Countries  to  the  south  of  the  equatorial  belt  are  less 
malarial  than  similar  latitudes  to  the  north,  and  in  those  south  of 
the  30th  degree  of  latitude  malaria  is  all  but  unknown. 

Etiology. — Although  not  the  only  factors  in  determining  the 
prevalence  of  malarial  fevers,  there  is  no  doubt  that  a  marshy  soil 
and  a  high  mean  temperature  are  favouring  agents.  The  delta  of  a 
great  river,  and  low-lying  land  possessed  of  a  high  subsoil  humidity, 
as  at  the  foot  of  a  mountain  range,  are  the  special  habitats  of 
paludism.  Freshly-broken  soil,  especially  virgin  soil,  is  often  inti- 
mately connected  with  outbreaks  of  malaria. 

In  all  warm  climates  particular  seasons  of  the  year  are  associated 
with  special  hability  to  fever,  and  to  the  different  seasons  fevers 
possessing  different  types  are  ascribed.  So  pronouncedly  is  this  the 
case,  that  such  names  as  "  spring  and  early  summer  intermittents  " 
and  "  gestivo-autumnal "  are  used  to  divide  one  class  from  the  other, 
which,  as  their  names  indicate,  prevail  during  the  spring  and 
autumn  respectively.     The  "  unacclimatised  "  European  seems  more 


MALARIA  AND   MALARIAL  FEVERS  417 

predisposed  to  attacks  of  malarial  fever  than  the  coloured  races 
native  to  hot  countries.  Children  and  young  adults  are  specially 
liable  to  malarial  infection,  but  old  people  of  long  residence  in  tropical 
countries  are  by  no  means  immune.  Females  are  not  less  prone  to 
malaria  than  males,  but  they  are  usually  less  exposed  to  its  influence. 

The  malarial  parasites. — It  was  not  until  the  year  1880, 
when  Laveran  discovered  the  parasites  in  the  blood  of  persons 
suffering  from  malarial  fever,  that  we  had  any  scientific  knowledge 
of  the  etiology  of  malaria. 

The  organism  is  termed,  usually,  the  "  plasmodium  malarise." 
The  name  is  biologically  incorrect,  as  the  parasite  is  in  no  sense  the 
large  multinuclear  mass  of  protoplasm  which  the  designation  would 
indicate.  Zoologically,  the  malarial  parasite  is  referred  to  the 
Protozoa,  grade  Corticata,  class  Sporozoa ;  and  of  the  Sporozoans  it 
most  nearly  resembles  the  Coccidia. 

Examination  of  the  blood  for  the  Plasmodium  malar  ice. — Wash  the 
tip  of  a  finger  with  soap  and  water  ;  dry  the  part  and  then  wipe  it  with 
ether  or  alcohol.  Tie  a  cord  round  the  root  of  the  finger  and  prick  the 
pulp  with  a  sterilised  needle.  Wipe  away  the  first  drop  of  blood  that 
issues,  and  with  a  clean  cover-glass  Ughtly  touch  the  issuing  blood  so 
that  a  minute  quantity  adheres  to  its  under  surface.  Place  the  cover- 
glass  so  charged  on  a  clean  slide  without  pressure  and  examine  by  yVth 
inch  oil-immersion  lens.  A  number  of  such  specimens  may  be  mounted 
in  a  similar  manner,  and  to  prevent  evaporation  it  is  well  to  "  ring  "  the 
cover-glass  with  vaseline.  Freshly -drawn  blood  so  prepared  may  be 
used  for  several  hours  for  purposes  of  examination. 

To  staiji  the  malarial  parasite. — Instead  of  using  a  cover-glass  to 
receive  the  blood,  Manson  recommends  that  a  piece  of  thin  paper  be 
made  to  touch  the  drop  of  blood  as  it  issues  from  the  finger.  The 
paper  so  charged  is  then  drawn  along  the  surface  of  the  slide  so  that  the 
blood  is  smeared  on  the  glass  in  a  thin  layer.  When  the  blood  stain  is 
dry,  absolute  alcohol  is  dropped  upon  its  surface  and  allowed  to  remain 
for  five  minutes,  when  the  alcohol  is  run  off  and  the  specimen  again 
dried.  To  the  blood  thus  fixed  a  staining  fluid  of  one  or  other  of  the 
following  substances  is  added  : — {a)  a  simple,  weak,  aqueous  solution  of 
methylene  blue ;  (b^  30  c.c.  of  a  concentrated  alcoholic  solution  of 
methylene  blue,  and  100  c.c.  of  solution  of  caustic  potash  (i  in  10,000)  ; 
or  (f)  an  aqueous,  2  per  cent  solution  of  methylene  blue,  mixed  with 
equal  parts  of  a  5  per  cent  solution  of  borax.  To  the  dried  and  fixed 
blood  on  the  slide  a  few  drops  of  the  staining  fluid  is  added,  allowed 
to  remain  for  thirty  seconds,  when  the  stain  is  washed  off  with  distilled 
water,  and  the  specimen  dried  between  layers  of  filter  paper  and  held 
over  the  flame  of  a  spirit  lamp,  and  mounted  in  xylol  balsam. 

VOL,  I  2  E 


41 8  MANUAL  OF  MEDICINE 

In  specimens  so  prepared,  the  red  blood  corpuscles  will  be  found 
unstained,  while  the  parasites  and  the  nuclei  of  the  leucocytes  are  tinged 
blue. 

The  benign  tertian  parasite. — i.  When  the  blood  of  a  patient 
suffering  from  tertian  fever,  to  whom  quinine  has  not  been  administered, 
is  examined  some  eight  hours  after  the  temperature  attending  a  paroxysm 
of  fever  has  fallen  to  the  normal,  the  characteristic  parasites  may  be 
seen  within  the  red  corpuscles.  They  occur  as  small,  colourless  bodies, 
changing,  by  amceba-like  movements,  to  shapes  resembling  a  disc,  a  star, 
a  cross,  or  a  ring.  At  first,  pigment  is  not  to  be  seen  except  occa- 
sionally, as  a  few  irregularly  distributed  granules  near  the  periphery  of 
the  parasites.  2.  If  a  specimen  of  blood  from  the  same  patient  is 
examined  some  eight  hours  later,  it  will  be  observed  that  the  hyaline- 
looking  bodies  within  the  red  corpuscles  have  increased  in  size,  that  the 
amoebic  movements  are  more  active,  that  the  pigment  has  increased  in 
quantity  and  activity,  that  the  red  corpuscle  enveloping  the  parasite  is 
paler  in  colour  and  has  increased  in  bulk  beyond  its  normal  limits. 
3.  Were  the  blood  of  the  same  patient  submitted  to  exammation  towards 
the  end  of  the  forty-eight  hours'  interval  which  characterises  the  disease, 
further  important  changes  can  be  made  out.  The  parasite  has  increased 
in  bulk  to  such  an  extent  that  it  is  difficult  to  see  the  pale  attenuated 
remnant  of  the  distended  red  corpuscle.  The  pigment  movement  is 
arrested  and  its  granules  collect  towards  the  centre  of  the  organism  in 
two  or  three  clumps.  The  hyaline -looking  surface  of  the  parasite 
becomes  more  granular,  and,  commencing  at  the  periphery  and  extending 
towards  the  centre,  fine  striations  appear  which  finally  cause  a  complete 
segmentation,  dividing  the  parasite  into  twelve  to  thirty  leaflets.  This 
is  no  doubt  a  true  segmentation,  the  whole  process  being  connected  with 
reproduction,  and  the  resulting  leaflets  are  the  young  spores.  Finally, 
the  red  corpuscular  tissue  containing  the  parasite  gives  way  and  the  spores 
and  pigment  escape  into  the  liquor  sanguinis.  The  free  spores  appear 
as  hyaline  protoplasmic  spherules  possessing  a  central  refracting  area. 
Although  the  process  has  not  actually  been  observed,  the  free  spores  are 
believed  in  many  instances  to  gain  access  to  adjacent  red  corpuscles, 
where  the  phenomena  of  growth  and  sporulation  are  again  proceeded 
with.  Others  of  the  parasites  appear  to  increase  in  size,  exhibit  a  dancing 
movement  in  their  pigment,  and  after  violent  agitation  throw  out  unpig- 
mented  flagella,  which  become  detached  and  float  away,  losing  them- 
selves amongst  the  corpuscles. 

When  the  blood  of  a  person  subject  to  malarial  fever  is  examined, 
by  one  experienced  in  the  microscopical  phenomena  of  malaria,  it  is 
easy  to  state  not  only  what  type  of  fever  prevails,  but  also  to  predict  the 
hour  at  which  the  paroxysm  may  be  expected.  Segmentation  occurs 
immediately  before  the  paroxysm,  and  with  the  rupture  of  the  containing 
red  corpuscles,  and  the  escape  of  the  spores  and  pigment,  it  would  seem 


MALARIA   AND    MALARIAL   FEVERS  419 

as  though  a  toxic  agent  found  its  way  into  the  blood,  causing  the  signs 
and  symptoms  of  an  attack  of  ague  or  other  form  of  fever. 

^\'hen  all  the  parasites  in  the  blood  mature  at  the  end  of  forty-eight 
hours,  tertian  fever  will  result,  but  if  a  certain  number  mature  twenty- 
four  hours  earlier  than  the  remaining  half,  the  fever  will  exhibit  the 
quotidian  type. 

The  benign  quartan  parasite. — When  the  blood  of  a  patient 
suffering  from  the  quartan  type  of  malarial  fever  is  examined  within 
twelve  hours  after  the  subsidence  of  a  paroxysm,  a  parasite  will  be  found 
within  the  red  corpuscles  well-nigh  indistinguishable  from  the  pale 
amoebic  body  described  as  met  with  in  the  tertian  type.  When,  how- 
ever, the  time  for  the  recurrence  of  the  paroxysm  approaches,  say  sixty- 
two  hours  after  the  last  attack,  sufficiently  marked  differences  are  met 
with,  which  enable  a  conclusive  diagnosis  to  be  established  by  micro- 
scopical examination,  whereby  the  quartan  may  be  distinguished  from  all 
othe    types. 

The  quartan,  as  compared  with  the  tertian,  parasite,  (i)  possesses  a 
more  definite  outline  ;  (2)  the  amoebic  movements  are  slower  ;  (3)  the 
pigment  is  darker  in  colour  and  coarser ;  (4)  segmentation  begins 
some  ten  hours  before  the  expected  paroxysm,  when  some  six  to  twelve 
leaflets  (spores)  only  are  formed.  Subsequently  the  escaped  spores 
behave,  as  regards  occupation  of  other  corpuscles  and  flagellation,  as  in 
the  case  of  the  tertian  parasite. 

\\Tien  the  quartan  parasites,  present  in  the  blood,  preserve  the  same 
stage  of  development,  fever  will  recur  every  seventy-two  hours.  With 
quartan  parasites  exhibiting  two  cycles  of  maturation,  paroxysms  of  fever 
will  occur  two  days  running,  with  a  third  day's  freedom  from  pyrexia. 
This  type  is  known  as  the  "double  quartan."  When  quartan  parasites, 
presenting  three  groups  of  development,  are  met  with,  paroxysms  of 
fever  will  recur  daily — the  "  triple  quartan." 

Malignant  or  aestivo-autumnal  parasites :  the  parasites  of  the 
irregular  malarial  fevers. — Three  forms  of  parasite — (i)  the  pigmented 
quotidian  ;  (2)  the  unpigmented  quotidian  ;  and  (3)  the  malignant  tertian 
■ — are  associated  with  the  so-called  malignant  types  of  fevers  ;  and  the 
crescent-shaped  parasite,  the  "gamete" — sexual  form — of  the  malignant 
tertian  parasite.  The  differences  between  the  benign  and  malignant 
parasites  may  be  summed  up  as  follows  : — (i)  The  cycle  of  development 
of  the  parasites  of  the  malignant  type  are  not  so  clearly  defined  as 
is  the  case  with  the  benign  ;  it  is  believed  to  extend  to  twenty-four  and 
forty-eight  hours  ;  (2)  the  malignant  parasites  do  not  mature  in  groups, 
but  independently,  as  it  were,  sonie  appearing  in  the  early  intra-corpuscular 
stage,  whilst  others  are  met  in  all  stages  up  to  complete  maturation  and 
sporulation  in  the  same  specimen  ;  (3)  the  peripheral  blood  shows  but 
little  evidence  of  the  presence  of  the  segmenting  parasites  ;  they  have 
to  be   searched  for  post-mortem   in   the   deeper  viscera,   especially  the 


420  MANUAL  OF  MEDICINE 

spleen  and  in  the  marrow  of  the  bones  ;  (4)  in  their  earliest  stages  the 
benign  and  malignant  parasites  resemble  one  another  closely,  but  later 
fairly  well-marked  features  serve  to  differentiate  them  ;  in  the  malignant 
varieties  the  parasite  is  much  smaller,  rarely  occupying  more  than  one- 
third  of  the  red  corpuscle ;  the  shape  varies  from  a  ring-like  body  with 
high  refractive  power  and  a  central  darker  area  to  that  of  a  hyaline  mass 
endowed  with  active  amoeboid-like  movements  ;  these  conditions  may 
alternate  once,  twice,  or  thrice,  the  one  shaped  body  changing  to  the  other 
with  alacrity  ;  (5)  the  pigment  is  for  the  most  part  scanty  ;  (6)  the  red 
corpuscle  containing  the  parasite  becomes  crenate  and  wrinkled,  and 
often  assumes  a  dark  green  hue — the  "brassy  body"  of  some  writers. 
Sporulation  proceeds  as  in  the  benign  forms,  and  the  ultimate  destina- 
tion of  the  benign  and  malignant  parasites  seems  analogous. 

Cresceiit-shaped  bodies. — In  a  case  of  remittent  or  continued  malarial 
fever,  which  has  lasted  a  week  or  more,  the  "  crescent-shaped  "  body  is 
to  be  met  with,  first  in  the  blood  of  the  organs,  and  later  in  smaller 
numbers  in  the  peripheral  blood.  As  the  name  implies,  the  parasite  is 
crescent-shaped,  and  in  the  concavity  of  the  arch  stretching  between  the 
horns  is  to  be  seen  the  remains  of  the  red  corpuscular  host,  altered  some- 
what in  shape  and  colour.  The  pigment  may  be  either  diffused  through 
the  mass  of  the  parasite,  or  it  may  appear  as  rods  collected  into  a 
central  clump. 

The  significance  of  the  "crescent"  bodies  is  subject  to  several 
interpretations.  Some  have  believed  them-  to  be  a  separate  parasite, 
others  that  during  the  continuance  of  the  fever  a  certain  number  of  the 
recognised  parasites,  instead  of  sporulating,  increase  in  size,  acquire 
pigment,  and  destroy  the  red  corpuscles  they  inhabit.  They  are  now 
known  to  be  the  gametes  of  the  malignant  parasite.  ]\Ianson"s  inter- 
pretation of  the  crescent  bodies  is,  that,  as  they  seem  incapable  of 
further  development  in  the  blood,  and  as  they  are  passive  agents  so  far 
as  the  appearance  of  fever  is  concerned,  they  are  the  means  by  which 
the  "  extra-corporeal "  life  of  the  parasite  is  maintained  in  media  other 
than  the  human  blood  and  body,  and  that  their  flagellation  is  a  neces- 
sary part  in  the  life-history  of  the  parasite. 

When  crescent  -  bearing  blood  is  exposed  to  the  air  for  a  few 
minutes,  and  examined  microscopically,  the  crescent  body,  after  some 
fifteen  to  thirty  minutes,  shows  signs  of  activity.  The  pigment  accumu- 
lates in  the  centre  of  the  parasite,  its  granules  dance  about,  and  its 
whole  body  becomes  agitated,  until  suddenly,  from  the  circumference, 
flagella,  two  to  five  in  number,  shoot  forth  and  lash  about  in  restless 
activity.  The  flagella  subsequently  separate  from  the  parasite,  and  move 
away  amongst  the  corpuscles,  leaving  the  parent  body  still  and  passive. 
T]ie  part  the  mosquito  plays  as  the  ^'■extra-corporeal"  host  of  the 
Plasmodium  malarice. — Several  observers  lay  claim  to  the  suggestion 
that  the  spread  of  malaria  was  in  some  way  connected  with  mosquitoes. 


MALARIA  AND   MALARIAL  FEVERS  421 

Manson,  however,  was  the  first  to  put  the  theory  on  a  scientific  basis, 
and  Major  Ross  in  1895  undertook  the  investigation  of  the  subject 
practically.  Manson  was  prompted  in  his  contention  by  his  investigations 
as  regards  the  part  the  mosquito  played  in  the  life-history  of  the  filariae, 
and  by  his  firm  belief  that  the  flagellation  of  the  parasite  after  its 
removal  from  the  body  had  a  meaning  and  purpose.  He  believed  that 
the  mosquito,  after  extracting  the  blood  of  malarial  persons,  served  as 
the  host  in  which  flagellation  was  carried  on,  and  that  this  process  was 
but  one  stage  in  the  extra-corporeal  life  of  the  parasite.  Ross,  when  he 
commenced  his  investigation,  soon  proved  the  truth  of  the  initial  stages 
by  finding  that  in  the  mosquito's  stomach  70  per  cent  of  the  crescent 
bodies  developed  flagella.  For  a  time  no  further  trace  of  the  organism 
could,  however,  be  found,  until,  after  a  long  and  patient  search,  the 
pigmented  bodies  characteristic  of  malarial  infection  were  found  in  the 
walls  of  the  mosquito's  stomach.  Not,  however,  in  all  mosquitoes, 
and  it  was  only  after  lighting  upon  the  "  dappled-winged "  and  the 
"  gray"  mosquitoes  that  this  phenomenon  was  discovered.  Following 
the  teaching  and  example  of  Professor  M 'Galium  of  the  Johns  Hopkin's 
University,  U.S.A.,  Ross  turned  his  attention  to  the  parasites  met  with 
in  the  blood  of  certain  birds.  In  the  stomachs  of  birds  ample  proof 
was  to  hand  of  flagellation.  The  flagella  were  found  to  break  away 
and  impregnate,  or  at  least  occupy  neighbouring  cells,  and  produce 
melanin  in  quantity.  The  cells  so  impregnated  Ross  traced  into  the 
stomach  walls  of  the  mosquito,  and  observed  that  they  protruded  on  the 
outer  surface  of  the  stomach  towards  the  body  cavity  of  the  animal. 
Whilst  this  "  coccidia  "-like  process  was  going  forward,  the  protoplasm 
of  the  cells  changed  to  rod-like  bodies — sporozoids.  In  the  body  cavity 
Ross  was  able  to  find  these  dark  rod-like  bodies  freed  of  their  enclosing 
envelope,  and  scattered  throughout  the  cavity  and  in  the  blood  of  the 
mosquito.  Finally,  they  were  found  in  what  appeared  to  be  the  salivary 
or  poison  glands  of  the  mosquito,  and  even  in  the  ducts  of  these 
glands  leading  to  the  proboscis. 

Inferring  that  these  rods  might  be  the  infective  medium,  Ross  next 
subjected  healthy  birds  to  mosquito  bites,  and  had  the  satisfaction  of 
finding  the  developed  parasite  in  the  blood  of  these  birds  after  an 
incubation  period  of  from  five  to  nine  days.  So  far  as  bird  and 
mosquito  relations  go,  the  cycle  of  their  parasites  has  been  proved, 
and  the  facts  accumulated  around  the  human  malarial  parasite  seem 
to  indicate  an  analogous,  if  not  an  identical  process.  In  fact  Grassi, 
Bastianelli,  and  Bignami,  have  lately  proved  by  direct  experiment  this 
phenomenon  also  in  man. 

The  parasite.- — The  anatomy  of  the  parasite  is  most  readily  studied 
when  subjected  to  staining  by  the  boro-methylene  method.  It  is  then 
seen  to  possess  a  deeply-stained  nucleolus,  a  clear,  unstained,  vesicular 
nucleus,  and  a  lightly-stained  protoplasmic  surrounding. 


422  MANUAL  OF   MEDICINE 

The  tnelanin. — The  pigment  met  with  in  malaria  is  derived  from 
the  disintegrated  haemoglobin.  It  resists  the  action  of  strong  mineral 
acids  ;  it  is  decolorised  by  ammonimn  sulphide  in  solution,  and  also  by 
free  alkalies.  Although  derived  from  so  richly  heematinic  a  substance 
as  haemoglobin,  no  iron  is  found  in  its  composition. 

Phagocytosis. — Many  leucocytes  in  the  blood  of  persons  suffering 
from  any  form  of  malarial  fever  are  seen  to  contain  either  one  or 
more  of  the  parasites,  or  the  leucocyte  may  engulf  the  parasite  and  the 
red  corpuscle  containing  it.  The  power  of  the  phagocytes  to  attack 
foreign  elements  in  the  blood  extends  also  to  the  flagellse  and  flagellate 
bodies,  and  in  many  the  melanin  granules  are  all  that  is  to  be  seen  to 
represent  what  once  was  a  living  parasite.  The  phagocytes  have  no 
doubt  a  salutary  influence,  and  were  they  in  sufficient  numbers  to  cope 
with  the  influx  of  parasites,  they  would  annul  their  baneful  effects  entirely. 
It  can  easily  be  believed  that  the  blood  of  all  persons  living  in  a  paludal 
area  is  infected  to  some  extent  by  the  prevailing  parasite,  and  it  is  in 
the  power  of  the  phagocytes,  by  their  scavenging  properties,  to  afford 
protection  or  so-called  immunity.  The  writer  has  found  phagocytes  in 
numbers  in  the  blood  of  healthy  persons  dwelling  in  malarial  districts, 
but  when  fever  seized  them  the  phagocytes  almost  entirely  disappeared, 
to  re-appear  once  more  as  the  paroxysm  subsided. 

Clinical  features  of  malarial  infection. — I.  Intermittent 
FEVERS. — Quotidian,  tertian,  and  quartan  fevers  exhibit  the  three 
stages  characteristic  of  ague. 

(i)  The  cold  stage  is  ushered  in  by  a  feeling  of  lassitude,  frontal 
headache,  yawning  and  stretching,  or  a  feeling  of  nausea.  Soon 
the  patient  looks  cold  and  feels  cold,  and  a  violent  rigor  supervenes. 
The  skin  is  cold  to  the  touch,  but  the  temperature  of  the  mouth,  or 
more  marked  still  that  of  the  rectum,  is  raised  from  the  first,  and 
speedily  rises,  even  during  the  rigor,  to  the  maximum  105°  or  106°. 
The  cold  stage  may  last  from  a  few  minutes  to  an  hour  or  more. 

(2)  The  hot  stage. — The  skin  during  the  hot  stage-  is  dry  and 
burning  to  the  touch,  the  face  flushes  and  the  pulse  strikes  full  and 
strong.  The  patient  desires  to  be  rid  of  warm  covering,  and  com- 
plains of  intense  thirst,  a  throbbing  headache  and  pains  in  the  limbs. 
Delirium,  characterised  usually  by  a  rambling  talk  in  adults,  and 
not  unfrequently  accompanied  by  convulsions  in  children,  is  not 
uncommon.  The  hot  stage  continues  for  an  hour  or  two  and  bears 
an  inverse  ratio  to  the  cold  stage ;  the  shorter  the  cold  stage  the 
longer  the  hot  and  vice  versa. 

(3)  The  sweating  stage.  —  With  the  appearance  of  profuse 
perspiration  the  restlessness  and  pains  subside,  and  after  free 
perspiration  for  two  or  three  hours  the  paroxysm  is  over. 


MALARIA   AND   MALARIAL  FEVERS  423 

Strictly  speaking  there  is  no  such  disease  as  a  quotidian  ague  ; 
as  already  explained,  the  daily  recurrence  of  fever  is  either  a  double 
tertian  or  a  triple  quartan.  The  typical  intervals  of  the  regular 
intermittent  are  twenty-four,  forty-eight,  and  seventy-two  hours  ; 
when  succeeding  attacks  appear  earlier  than  the  typical  times  the 
fever  is  said  to  "  anticipate  " ;  when,  on  the  other  hand,  the  period 
is  delayed  the  fever  is  said  to  be  "postponed."  The  latter  type  is 
regarded  as  evidence  of  abatement  in  severity.  After  a  paroxysm 
of  fever  is  over  the  temperature  falls  considerably  below  the  normal, 
and  according  to  the  excess  of  the  high  temperature  so  is  the  fall 
proportionate.  The  writer  estimated,  from  a  careful  study  of  many 
temperature  charts,  that  for  every  degree  of  rise  above  the  normal 
there  was  a  corresponding  fall  of  one-eighth  of  a  degree  below  the 
normal,  after  allowing  for  the  diurnal  rise  and  fall  of  health. 

11.  Remittent  fever.  —  At  the  onset  remittent  fever  is 
attended  by  a  feeling  of  dullness  which  may  extend  over  several 
days,  or  it  may  be  ushered  in  by  a  sharp  rigor.  The  usual  initial 
signs  and  symptoms  of  "  feverishness  "  are  present,  and  these  are 
followed  by  a  heightened  temperature,  which  continues  with  but 
slight  abatements  or  remissions.  Abortive  attempts  at  sweating 
may  occur,  accompanied  by  a  corresponding  decline  of  the  body 
heat,  but  the  temperature  does  not  fall  to  the  normal.  So  per- 
sistently is  the  fever  maintained  in  some  cases  that  the  fever  is 
named  "continuous"  or  "continued"  fever.  When  vomiting  is 
severe  the  name  "bilious  remittent"  is  employed  to  designate  the 
type.  Other  names,  such  as  "gastric  and  typhoid  remittent  and 
typho-malarial  fever,"  indicate  the  resemblance  of  the  remittent  type 
of  malarial  fever  to  typhoid.  So  pronounced  is  this  at  times  that  it 
is  only  by  examination  of  the  blood  and  the  evidence  of  a  carefully 
kept  temperature  chart  that  the  diagnosis  can  be  established. 
!Many,  if  not  most  of  the  so-called  aborted  typhoids  may  be  real 
remittents.  There  is  no  doubt  we  have  in  the  tropics  a  fever  which 
is  wont  to  follow  a  weekly  cycle.  Should  quinine  prove  of  uncertain 
benefit  after  a  two  or  three  days'  trial,  and  the  fever,  if  malarial,  be 
left  to  run  its  course,  it  will  end  on  either  the  seventh  or  the  four- 
teenth day.  So  persistently  did  these  dates  of  subsidence  occur  in 
the  practice  of  the  writer,  that  he  termed  them  a  one  week,  a  two 
week,  and  even  a  three  week  fever,  and  by  observing  the  behaviour 
of  the  temperature  during  the  first  two  or  three  days  of  the  illness, 
it  was  possible  to  predict  the  day  of  its  prospective  fall. 

In  the  blood  of  persons  suffering  from  remittent  fever  the 
malignant    or    Estivo-autumnal  parasite   is   found ;    and   after    the 


424  MANUAL  OF   MEDICINE, 

fever  has  lasted  one  week  the  crescent -shaped  bodies  are  to   be 
seen. 

III.  Irregular  forms  of  fever  are  also  associated  with  the 
presence  of  the  malignant  parasite  in  the  blood.  When  intermissions 
are  short  and  the  paroxysms  long,  extending  even  to  twenty  hours  or 
more,  these  fevers  form  a  connecting  link  between  true  intermittents 
and  the  remittent  group. 

IV.  Pernicious  malarial  fever. — When  any  one  organ,  or 
group  of  organs,  is  singled  out  to  bear,  as  it  were,  the  intensity  of  the 
attack  of  fever,  and  the  organ  is  seriously  affected,  the  name 
"  pernicious "  is  applied  to  the  condition.  (a)  In  the  cerebral, 
comatose,  or  apoplectic  type  the  nervous  system  is  so  severely 
implicated  that  unconsciousness  supervenes  and  the  patient  may 
die  in  coma ;  {b)  algide  malaria  attacks  the  gastro-intestinal  tract  so 
violently  that  the  symptoms  resemble  those  of  cholera ;  {c)  should 
the  kidneys  have  to  bear  the  brunt  of  the  paroxysm,  hematuria  may 
be  present. 

V.  Long  interval  fevers. — It  is  not  uncommon  to  meet  with 
patients  who  get  attacks  of  fever  at  intervals  of  months  or  years,  or 
who  have  recurrences  of  fever  long  after  they  have  settled  in  a 
non-malarial  country.  In  fact,  many  tropical  residents  never  get  an 
attack  of  fever  until  they  take  up  their  abode  in  a  temperate  or  cold 
climate.  In  such  cases  the  parasite  attains  a  "  latent  phase  "  and 
develops  into  activity  only  after  its  human  host  has  been  exposed  to 
some  severe  mental  or  bodily  strain. 

The  effect  of  malarial  infection.  —  Anaemia  and  enlarged 
spleen  are  the  two  prominent  conditions  set  up  by  long-continued  ex- 
posure to  paludal  infection.  Anaemia  is  regarded  as  a  constant  result 
of  residence  of  Europeans  in  tropical  countries ;  and  in  all  prob- 
ability this  is  to  be  ascribed,  in  the  majority  of  instances,  even  in 
persons  who  have  never  had  ague  or  remittent  fever,  to  the  direct 
action  of  the  malarial  parasites  on  the  blood  corpuscles,  rather  than 
to  the  effect  of  mere  "  climate." 

With  each  paroxysm  of  fever  the  red  corpuscles  decrease  in 
number.  Instead  of  the  normally  estimated  5,000,000  red  corpuscles 
in  I  cubic  mm.  of  the  blood,  oligocythaemia  may  proceed  to  such 
an  extent  that  their  number  may  be  reduced  to  one-fifth  or  even 
one-tenth  of  the  normal  quantity.  It  is  estimated  that  in  each  cubic 
mm.  of  blood  1,000,000  red  corpuscles  may  disappear  in  a  single 
paroxysm. 

Poikilocytosis^  more  especially  in  fevers  of  the  malignant  t\pes,  is 
to  be  observed,  the  red  corpuscles  showing  numerous  differences  in 


MALARIA  AND   MALARIAL  FEVERS  425 

shape.  Not  only  is  the  actual  quantity  of  hcemoglobin  diminished, 
but  after  continued  recurrences  the  remaining  haemoglobin  is 
lessened  in  physiological  value. 

Malarial  angemia  is  characterised  by  the  usual  pallor  of  the  skin 
and  mucous  membranes,  and  the  attendant  circulatory,  digestive,  and 
renal  troubles.  Vitality  is  markedly  lowered  and  the  spirits  subject 
to  fits  of  serious  depression. 

The  liver  is  to  be  found  enlarged  and  somewhat  tender,  and  the 
spleen  in  all  chronic  malarial  affections  increased  in  bulk,  it  may  be 
to  an  enormous  extent. 

Post-mortem  appearances. —  In  addition  to  evidence  of 
anemia,  parasitic  infection  of  the  red  corpuscles  and  widely  spread 
pigmentation,  the  following  conditions  are  met  with. 

The  spleen  is  enlarged  at  times  so  that  it  weighs  several  pounds, 
and  the  splenic  tissue,  when  death  has  resulted  after  long-standing 
illness,  is  dark -gray  in  colour,  and  firm  in  consistence.  Micro- 
scopically examined  the  melanin  will  be  seen  to  occupy  the 
txabeculae  and  blood-vessel  walls,  and  the  macrophages  are  deeply 
pigmented.  The  liver  is  usually  somewhat  enlarged,  the  tissue  is  of 
a  dark  gray  colour,  and  microscopically  the  capillary  walls  and  the 
phagocytes  are  found  to  be  loaded  with  parasites.  Cirrhosis  is  some- 
times met  with,  or  again  small  necrotic  areas  are  seen  scattered 
through  the  liver  substance. 

The  kidneys,  in  addition  to  their  darkened  colour,  are  somewhat 
enlarged,  and  in  the  glomeruli  pigment  is  readily  detected. 

The  peritoneum  and  the  mucous  membrane  of  the  alimentary 
canal  from  the  stomach  to  the  rectum  is  stained  a  slate-gray  colour. 

The  brain  appears  darkened  in  colour,  and  in  the  red  corpuscles 
in  the  capillaries  are  seen  parasites  in  large  numbers.  Even  the 
endothelial  lining  of  the  capillaries  is  found  swollen  and  pigmented. 
The  marrow  of  the  long  bodies  becomes  almost  black,  as  the  result  of 
prolonged  malarial  infection.  Macrophages  similar  to  those  met  with 
in  the  spleen  are  found  loaded  with  pigment,  and  in  the  marrow 
itself  pigmentary  masses  are  not  uncommon. 

Prognosis. —  The  prognosis  in  the  case  of  benign  forms  of 
fever,  so  far  as  the  life  of  the  patient  is  concerned,  is  good,  but 
repeated  attacks  may  so  enfeeble  a  patient  the  subject  of  malaria 
that  a  chronic  cachexia  of  very  grave  import  may  supervene. 

The  malignant  malarial  fevers  are  attended  by  considerable 
direct  danger  to  hfe,  and  paroxysm  may  succeed  paroxysm,  leading 
to  fatal  results.  When  pneumonia,  dysentery,  or  nephritis  com- 
plicate malarial  infection,  the  prognosis  is  grave  indeed.     Malarial 


426  MANUAL  OF  MEDICINE 

cachexia  tends  to  disappear  after  the  patient  has  spent  a  couple  of 
years  in  a  healthy  non-malarial  locality ;  but  any  subsequent  illness 
is  liable  to  assume  features  of  a  malarial  type.  Several  forms  of 
neuritis  and  paralysis  are  ascribed  to  malaria ;  these  also  tend  to 
disappear  when  the  malarial  district  is  left  behind. 

Prophylactic  measures. — I.  Personal  prophylaxis  consists 
of — avoiding  chills,  changing  damp  clothing  at  once,  sleeping 
under  mosquito  netting  and  not  on  the  ground  level,  moderation  in 
eating,  drinking,  and  smoking,  wearing  flannel  next  the  skin,  and 
protecting  the  head  by  a  sun  hat.  Loss  of  sleep,  fatigue  and  mental 
anxiety  conduce  to  pave  the  way  for  incursion  of  fever. 

II.  Afedkinal  prophylactic  measures  resolve  themselves  into  the 
taking  of  quinine.  Quinine  should  be  taken  before  going  out  of 
doors  when  the  place  of  temporary  residence  is  known  to  be  highly 
malarial,  or  when  the  season  of  the  year  predisposes  to  attack.  Five 
grains  is  the  usual  dose,  but  if  the  drug  has  to  be  continued  for 
several  weeks  three  grains  will  be  sufficient.  Plehn  holds  that  five 
grains  every  fifth  day  is  ample  protection.  When  a  person  living  in 
a  malarial  district  is  over- fatigued,  catches  cold,  or  is  run  down 
from  any  cause,  a  five-grain  dose  of  quinine  taken  immediately  may 
prevent  evil  consequences  resulting. 

III.  General  prophylaxis. — Subsoil  drainage  is  the  only  known 
expedient  of  public  sanitation  which  can  be  said  to  directly  and 
primarily  affect  the  prevalence  of  malarial  fever.  Cultivation  of  the 
soil,  planting  trees,  especially,  it  is  averred,  the  eucalyptus  tree,  the 
supply  of  good  water,  and  the  improvement  of  house  and  town 
drainage  are  important  adjuncts.  From  what  we  know  of  the 
mosquito,  its  habits  and  its  proved  connection  with  the  life  of  the 
malarial  parasite,  boiling  the  water  used  for  drinking,  cooking,  and 
even  for  bathing  purposes  is  a  safe  precaution.  The  anopheles 
species  of  mosquito  is  the  insect  which  has  so  far  been  accredited  as 
the  intermediary  host  of  the  malarial  parasite.  The  ova  of  the 
insect  are  deposited  in  shallow,  stagnant  pools,  and  there  the 
mature  insect  is  developed.  Local  prophylaxis  consists  in  sweeping 
out  these  pools  or  in  covering  the  water  by  kerosine,  turpentine,  or 
other  oily  substances. 

Treatment. — During  the  paroxysm  of  malarial  fever  the  patient 
should,  whenever  possible,  get  into  bed.  Flannel  should  be  worn 
and  the  linen  sheets  dispensed  with.  During  the  cold  stage  hot- 
water  bottles  and  extra  blankets  are  necessary,  and  warm  drinks  of 
weak  tea,  hot  water  and  freshly-made  lemonade  are  comforting. 
During  the  hot  stage  the  patient  must  be  prevented  throwing  off  the 


MALARIA   AND   MALARIAL  FEVERS  427 

extra  clothing  to  too  great  an  extent,  and  warm  drinks  are  to  be  freely 
supplied  unless  vomiting  supervenes,  when  ice  may  be  given  to 
suck.  When  the  sweating  stage  arrives  the  hot  bottles  must  be 
removed  from  the  bed,  the  excess  of  covering  reduced,  and  if  the 
pulse  is  weak  a  stimulant  may  be  given  with  the  warm  drinks. 
After  the  temperature  has  fallen  to  the  normal  the  surface  of  the 
body  should  be  wiped  dry,  and  fresh  flannels  and  blankets  supplied. 

Antipyretic  remedies  of  the  nature  of  antifebrine,  antipyrin,  and 
phenacetin  are  largely  used  in  the  treatment  of  malarial  fevers. 
Unless,  however,  the  temperature  during  the  hot  stage  becomes 
excessive  there  is  no  justification  for  their  use.  They  no  doubt 
procure  a  freer  perspiration,  but  it  is  improbable  that  they  curtail 
the  period  of  the  paroxysm.  When,  however,  the  temperature, 
in  adults  more  especially,  rises  above  105°,  phenacetin  is  perhaps 
the  safest  of  the  specially  antiphlogistic  remedies,  and  it  may  be 
given  in  ten-grain  doses  every  twenty  minutes  until  thirty  grains  are 
given.  The  same  rule  may  be  followed  with  antipyrin,  and  it  is 
wise  with  each  dose  to  give  a  drachm  or  two  of  brandy.  The 
writer  has  had  excellent  results  with  the  hypodermic  injection  of 
antipyrin,  on  one  occasion  reducing  a  temperature  of  107.6°  in 
twenty  minutes  to  103°,  and  in  twenty  minutes  more  to  100°  by  a 
hypodermic  of  five  grains  of  the  drug.  Should  other  means  fail, 
resort  may  be  had  to  the  wet  pack,  or  to  baths  in  which  the  tem- 
perature is  gradually  reduced  from  that  of  the  body  warmth  to 
extreme  coolness  by  the  addition  of  ice  to  the  water. 

Medicines. — The  medicinal  treatment  of  malarial  diseases,  be 
the  variety  what  it  may,  is  quinine ;  whether  as  the  sulphate,  the 
bisulphate,  or  the  hydrochlorate  is,  for  the  most  part,  a  question 
of  choice.  It  may  be  administered  in  solution  with  a  few  drops  of 
mineral  acid,  in  tabloids,  in  powders,  or  hypodermically ;  quinine 
in  the  form  of  pills,  more  especially  when  coated,  is  to  be  avoided. 
The  amount  of  quinine  to  be  exhibited  need  not  be  excessive ;  a 
fifteen-grain  dose  to  start  with,  followed  by  five  grains  every  four 
hours,  is  sufficient,  the  interval  and  amount  of  the  dose  increasing 
and  decreasing  respectively  as  the  symptoms  and  paroxysm  abate. 
The  time  of  administration  is  of  some  consequence ;  in  intermittent 
fevers  the  period  of  apyrexia  is  selected  and  the  drug  continued  up  to 
the  onset  of  the  paroxysm.  In  remittent  fevers  and  in  those  of  the 
more  continuous  type  quinine  must  be  given  at  regular  intervals 
without  regard  to  decline  in  temperature.  It  is  possible  that 
antiphlogistic  medicines — antipyrin  or  phenacetin  causing  a  lowering 
of  the  temperature  and   sweating — may   be   employed   with   some 


42  8  MANUAL  OF   MEDICINE 

advantage,  the  quinine  being  given  during  the  temporary  abate- 
ments. It  may  be  taken  as  an  axiom  that,  if  quinine  in  five-grain 
doses  has  been  administered  every  four  hours  for  three  days  with- 
out decided  effect,  the  case  is  most  certainly  not  one  of  malaria. 
When  vomiting  annuls  the  giving  of  quinine  by  the  mouth  it  may  be 
injected  hypodermically.  The  soluble  hydrobromate  or  lactate  ot 
quinine,  or  the  bisulphate,  may  be  used  dissolved  in  tartaric  acid 
(five  grains  of  tartaric  acid  dissolving  thirty  grains  of  the  sulphate). 
A  fifteen,  twenty,  or  even  thirty-grain  dose  of  either  of  these  drugs 
may  be  injected  into  the  subcutaneous  tissues  or  into  the  substance 
of  the  muscles.  Quinine  is  accused  of  possessing  several  disad- 
vantages ;  headache,  delirium,  deafness,  hasmaturia,  hsemoglobinuria, 
gastro-intestinal  derangements,  etc.,  are  laid  to  its  charge,  for  the 
most  part,  if  not  wholly  unjustifiably.  The  most  untoward  objec- 
tion is  the  tendency  to  a  deep-seated  abscess  and  wide  destruction 
of  the  skin  after  hypodermic  injection.  Opium  is  a  favourite  drug 
in  many  countries,  and  hypodermic  injections  of  morphia,  by  allaying 
feelings  of  malaise  and  nausea,  have  many  advocates  as  accessories 
to  quinine.  When  pernicious  fever  assumes  the  comatose,  algide,  or 
cerebral  types,  suitable  remedies  must  be  promptly  adopted.  Food 
must  be  administered  by  the  rectum  if  necessary  ;  heart  failure  must 
be  combated  by  stimulants  and  hypodermics  of  either  atropin  or 
strychnine.  Of  prepared  remedies  Warburg's  tincture  is  by  far  the 
most  reliable  and  beneficial ;  methylene  blue,  arsenic,  eucalyptus, 
ergot,  etc.,  etc.,  are  used  by  but  few  practitioners.  Euchinin,  the 
ethyl  carbonate  of  quinine,  also  finds  some  supporters. 

Malarial  cachexia  is  best  treated  by  removal  of  the  patient 
to  a  non- malarial  district.  A  temperate  or  even  cold  climate  is 
most  advantageous  for  invalids  suffering  from  chronic  tropical 
malaria.  Towns  and  the  sea-side  are  to  be  avoided,  and  prolonged 
residence  on  high  ground  is  imperative  if  speedy  and  thorough 
recovery  is  desired.  Drugs,  when  cachexia  is  marked,  are  of  little 
avail.  Arsenic  and  iron  serve  as  adjuvants  at  times,  and  at  times 
iron  does  harm.  Enlargements  of  the  spleen,  if  recent,  disappear, 
bnt  a  rhronicnlly  enlarged  spleen  may  defy  both  internal  and 
external  remedies  to  reduce  its  size. 

James  Cantlie. 


H^MOGLOBINURIC  FEVER  429 

H^MOGLOBINURIC    FEVER 

Syn.  Blackwater  Fever,  West  African  Fever    ■ 

A  specific  fever  restricted  in  its  geographical  distribution  and 
characterised  by  the  presence  of  haemoglobin  and  its  derivatives 
in  the  urine. 

Geographical  distribution. — The  disease  is  especially  pre- 
valent in  the  river  basins  of  Equatorial  Africa,  but  is  also  well 
known  in  the  Western  Hemisphere,  in  Cuba,  Venezuela,  and  the 
Southern  States  of  North  America.  It  has  been  met  with  in  a  more 
sporadic  form  in  East  Africa,  especially  in  the  Zambesi  basin ;  in 
Europe  it  has  been  seen  in  Italy  and  in  Greece.  Cases  have  been 
reported  from  India,  Java,  New  Guinea,  and  the  writer  met  with  a 
well-marked  case  in  Hong-Kong  occurring  in  a  medical  man  recently 
arrived  from  the  gold-fields  of  Siam.  Blackwater  fever  may  occur 
after  the  patient  has  left  the  countries  in  which  it  is  endemic. 

Etiology. — Three  beliefs  obtain  at  the  present  day  as  to  the 
cause  of  blackwater  fever. 

(i)  That  it  is  of  malarial  origin.  In  favour  of  this  contention 
it  is  argued  that  the  disease  occurs  only  in  those  who  have  suffered 
from  and  are  broken  down  by  malaria.  The  parasites  of  malaria 
are  usually  met  with  in  the  blood,  and  all  the  features  of  a  malarial 
paroxysm  accompany  blackwater  fever. 

Against  this  view,  it  must  be  stated  that  Laveran's  parasite  is 
not  invariably  found  in  the  blood  of  persons  suffering  from, 
hgemoglobinuric  fever  ;  that  in  some  rare  cases  the  disease  may 
occur  within  four  or  five  weeks  after  landing  on  the  West  Coast  of 
Africa,  and  before  malaria  has  had  time  to  cause  either  ansemia  or 
cachexia ;  that  the  very  limited  geographical  distribution  of  the 
disease  betokens  either  a  special  form  of  the  malarial  infection,  or 
a  toxic  agent  independent  of  the  malarial  parasite. 

(2)  Quinine  is  adduced  as  a  causative  agent.  The  chief  reason 
for  this  belief  no  doubt  lies  in  the  statement  that  the  administration 
of  quinine,  in  large  doses,  seems  to  cause  a  recurrence  of  haemo- 
globinuria  in  those  who  have  become  the  subject  of  the  disease. 
This  may  be  a  clinical  phenomenon,  but  it  is  hardly  worthy  of 
being  accepted  as  a  pathological  axiom.  Malaria  is  so  general 
and  the  administration  of  quinine  in  large  doses  so  universal  in 


430  MANUAL  OF  MEDICINE 

warm  climates,  that,  were  quinine  in  any  way  a  determining  cause 
of  the  disease,  the  geographical  distribution  of  hsemoglobinuria 
would  not  be  confined  to  a  few  definite  and  restricted  regions. 
That  quinine  may  do  harm  during  a  paroxysm,  or  may  induce  a 
relapse,  is  beside  the  question  of  the  etiology  of  the  disease. 

(3)  A  specific  agent  is  claimed  by  many  observers  as  the  cause 
of  blackwater  fever.  For  this  belief  there  is  much  to  be  said ;  every 
scientific  inference  points  in  this  direction.  Laveran's  parasite 
may  be,  and  no  doubt  is  associated  with  the  disease,  but  the 
association  may  be,  and  probably  is,  nothing  more  than  a  means 
whereby  the  patient's  strength  is  reduced  and  he  becomes  thereby 
liable  to  infection  by  the  specific  agent  of  hasmoglobinuria. 

Dr.  Sambon  holds  the  opinion  that  the  haimoglobinuric  fever 
in  man  is  caused  by  a  parasite  similar  to  that  which  causes  the 
hgemoglobinuric  fever  of  cattle  ;  in  other  words,  its  specific  agent 
belongs  to  that  group  of  hsemosporids  which  multiply  by  simple 
binary  division.  He  further  believes  that  paroxysmal  haemoglo- 
binuria  stands  to  blackwater  fever  in  the  same  relation  as  entero- 
colitis (the  dysentery  of  northern  latitudes)  to  tropical  dysentery,  the 
difference  in  mortality  arising  from  the  fact  of  blackwater  fever 
usually  supervening  on  persons  already  weakened  by  tropical 
malaria. 

Symptoms.  - —  Haemoglobinuric  fever  is  often  preceded  or 
accompanied  by  symptoms  of  malarial  infection. 

It  is  seldom  until  after  the  first  year  of  residence  in  a  black- 
water  fever  country  that  the  disease  develops,  and  the  third  year  is 
considered  to  be  the  most  likely  period  of  its  appearance.  At  any 
time  during  the  second  and  third  years  of  residence,  during  what 
seems  to  be  a  relapse  of  an  irregular  attack  of  fever,  the  patient  is 
seized  with  marked  rigors,  accompanied  by  headache,  pain  in  the 
loins,  numbness  in  the  extremities,  pain  in  the  epigastrium,  and 
distressing  vomiting  of  bile-stained  fluid.  The  temperature  suddenly 
rises  to  103°  or  104°  F.,  the  pulse  becomes  quick  and  small,  the 
breathing  increases  in  frequency,  and  the  patient  is  restless,  anxious, 
and  apprehensive.  The  urine  has  at  first  merely  a  red  hue,  but 
speedily  acquires  a  dark -brown  colour  and  a  thickened  consistency ; 
calls  to  micturate  are  frequent,  often  attended  with  pain,  and  more 
especially  if  the  urine  is  scanty.  When  the  fever  has  lasted  some 
hours  the  conjunctivae  and  the  skin  generally  assume  a  yellow 
tint,  caused  in  all  probability  by  the  acute  hsemolysis  which  is 
taking  place.  After  eight  to  twelve  hours  in  favourable  cases  the 
temperature  falls  rapidly,  with  profuse  and  exhausting  perspiration, 


H.'EMOGLOBINURIC  FEVER  431 

to  below  the  normal,  the  urine  soon  clears,  and  all  the  aches  and 
pains  disappear.  A  trace  of  albumen  may  remain  in  the  urine 
for  some  days  and  the  patient  continues  in  a  weak  state  for  a 
considerable  time. 

It  may  happen  that  no  subsequent  recurrence  takes  place,  but 
more  often  on  the  following  day  all  the  signs  and  symptoms  are 
repeated,  or,  on  the  other  hand,  the  feverish  attacks  resembling 
malarial  paroxysms  may  occur  without  the  accompanying  alterations 
in  the  urine. 

Pathology. — The  blood  in  blackwater  fever  usually  indicates  a 
pronounced  anaemia.  The  red  corpuscles  show  advanced  poikilo- 
cytosis,  their  shapes  being  multiform.  All  the  red  corpuscles  ap- 
pear blanched  as  if  deprived  of  their  haemoglobin.  Leucocytosis 
is  also  a  feature  of  the  blood  of  blackwater  fever,  the  polynuclear 
cells  being  especially  increased  in  numbers.  The  whole  of  the 
haemoglobin-producing  powers  of  the  blood  appear  to  be  concerned 
in  the  process,  and  it  would  seem,  as  suggested  by  IManson,  that 
some  toxic  solvent  agent  is  at  work,  whereby  not  only  the 
disintegrated  corpuscles,  but  also  the  uninfected  red  corpuscles, 
by  being  despoiled  of  their  hcemoglobin,  contribute  to  the  urinary 
feature.  When  the  urine  passed  during  a  paroxysm  of  blackwater 
fever  is  allowed  to  stand  a  sediment  results,  which,  when  examined, 
shows  granular  and  pigmentary  amorphous  matter,  large  granular 
casts  of  hemoglobin,  some  hyaline  casts,  a  few  red  blood  corpuscles 
and  epithelial  scales. 

The  viscera  are  not  characteristically  affected.  Black  pigmentary 
deposits  are  seen  in  the  situations  characteristic  of  malarial  in- 
fection ;  the  kidneys  show  cloudy  swelling  of  the  cells  lining  the 
tubules,  the  tubes  are  blocked,  and  yellow  and  black  pigments  are 
met  with  everywhere,  except  in  the  Malpighian  corpuscles.  The 
spleen  and  liver  cells  are  similarly  affected  as  regards  pigmentary 
deposits,  both  black  and  yellow. 

Staff  Surgeon -Major  Stendel  of  the  German  Army  made  an 
examination  of  the  blood  by  means  of  Fleischl's  hsemometer,  and 
found  that  the  amount  of  haemoglobin  present  oscillated  between 
50  and  21  per  cent  of  the  normal  standard.  In  two  other  cases 
the  quantity  was  too  small  to  be  determined  {Lancet,  July  27,  1895, 
p.  225)  by  the  instrument,  but  it  was  estimated  by  the  obser\'er  at 
not  more  than  5  and  8  per  cent  respectively.  He  lays  stress  upon 
the  prognostic  value  of  h?ematological  examinations. 

Diagnosis.' — -Yellow  fever  is  the  disease  with  which  blackwater 
fever   is   most   apt   to    be  confounded.      In  yellow  fever  the  urine 


432  MANUAL   OF  MEDICINE 

contains  albumen  at  an  early  stage  and  without  hjemoglobin  ;  in 
blackwater  fever  it  contains  cell-globulin,  not  albumen,  and  only 
when  dark  in  colour  from  haemoglobin.  Dark  urine  is  an  early 
feature  in  blackwater  fever.  The  vomited  matters  are  not  merely 
the  bile-stained  fluid  met  with  in  hsemoglobinuria,  but  consist  of 
the  disintegrated  red  corpuscles  and  coagulated  blood.  Neither 
thg  spleen  nor  liver  are  enlarged  in  yellow  fever,  and  post-mortem 
evidence  of  pigmentation  is  wanting. 

But  hgemoglobinuria  may  be  caused  by  organic  or  inorganic 
toxins,  such  as  potassium  chlorate,  arseniuretted  hydrogen,  sulphuric 
acid,  hydrochloric  acid,  phenol,  naphthol,  aniline,  chrysarobin,  pyro- 
galhc  acid,  etc.,  and  by  the  influence  of  cold  or  arduous  muscular 
exertions.  The  diagnosis  between  haemoglobinuria  arising  from 
such  causes  and  blackwater  fever  is  made,  however,  without  diffi- 
culty. The  paroxysmal  haemoglobinuria  of  temperate  climates  in 
many  respects  resembles  blackwater  fever,  but  it  is  rarely  a  fatal 
disease.  Moreover,  it  is  a  disease  but  occasionally  met  with  over 
widely  diffused  areas.  The  blackwater  fever  of  West  Africa  (and 
elsewhere)  is,  however,  a  frequent  ailment  in  these  regions,  and 
may  be  attended  by  a  mortality  as  high  as  60  per  cent  of  those 
attacked. 

Prognosis. — A  single  attack  of  blackwater  fever  may  be 
followed  by  complete  recovery.  Repeated  attacks  may  in  like 
manner  result  in  disappearance  of  the  malady.  When,  however, 
the  disease  persists,  when  remission  and  not  intermission  of  symp- 
toms prevail,  when  the  urine  becomes  scanty  or  is  suppressed,  a 
grave  prognosis  is  called  for.  Recovery,  however,  takes  place  from 
what  seems  well-nigh  hopeless  conditions. 

Unfavourable  symptoms  are  a  continuance  of  high  fever, 
persistent  vomiting,  purging  of  marked  severity,  suppression  of 
urine,  mental  depression,  restlessness  and  delirium,  deepening  of 
the  jaundiced  hue,  a  dry  tongue,  and  a  feeble  pulse.  Symptoms 
of  uraemia  usually  precede  a  fatal  termination. 

Treatment. —  During  the  paroxysm  of  blackwater  fever 
quinine  should  be  withheld.  Attempts  must  be  made  to  allay 
excessive  retching  by  giving  ice  to  suck,  and  by  mustard  plasters 
over  the  epigastrium.  Strength  must  be  maintained  by  rest  in  bed, 
by  giving  sips  of  brandy  and  water  or  champagne,  by  ether  hypo- 
dermically,  by  rectal  nutritive  enemata,  etc. 

Perspiration  should  be  encouraged  by  any  of  the  usual  methods. 
The  writer  has  found  good  results  from  the  administration  during 
the  attack  of  ten  drops  of  oil  of  turpentine  every  two  or  three  hours. 


KALA-AZAR  433 

When  blood  examinations  show  the  presence  of  the  malarial  parasite, 
quinine  must  be  resorted  to  when  once  the  paroxysm  of  blackwater 
fever  has  abated.  Should  repeated  attacks  of  haemoglobinuria  recur 
coincidently  with  the  administration  of  quinine,  the  drug  must  be 
withheld,  and  the  patient  removed,  if  possible,  from  the  district 
where  the  disease  is  endemic  to  a  temperate  climate. 

The  nephritis  which  sometimes  accompanies  an  attack  of  black- 
water  fever  must  be  treated  on  general  principles. 

James  Cantlie. 


KALA-AZAR 


An  epidemic  communicable  disease,  probably  malarial  in  nature, 
characterised  by  an  acute  onset  and  recurrent  accessions  of  fever, 
by  enlargement  of  spleen  and  liver,  by  anaemia  and  cachexia,  and 
by  a  high  death-rate.  The  disease  has  been  accurately  observed  in 
Eastern  Bengal  and  Assam  only. 

Kala-dukh  and  kala-jwar,  met  with  in  the  Purnea  (Bengal)  and 
Darjeeling  districts  respectively,  are,  in  all  probability,  kala-azar 
under  different  names. 

Etiology. — Considerable  divergence  of  opinion  concerning  the 
cause  of  kala-azar  has  up  to  the  present  obtained,  nor  can  it  be  con- 
sidered that  the  question  is  yet  settled.  The  first  systematic  inquiry 
into  the  etiology  of  the  disease  was  made  by  Major  Giles,  I. M.S., 
who  believes  kala-azar  to  be  "a  mixed  anaemia  brought  about  by 
ankylostomiasis  acting  on  a  population  worn  down  by  chronic 
malarial  poisoning."  Captain  Rogers,  I. M.S.,  as  the  result  of  his 
investigations  made  subsequently  to  Major  Giles's  report,  came  to 
the  conclusion  that  kala-azar  is  malarial  in  origin.  Against  the 
theory  of  the  disease  being  ankylostomiasis  it  may  be  urged  that 
ankylostomiasis  is  so  widespread,  not  only  in  Assam,  but  also 
throughout  India,  the  Malay  Peninsula,  and  the  Archipelago  that 
it  is  improbable  so  definite  a  set  of  symptoms  as  are  described 
under  the  kala-azar  of  Assam  could  be  set  up  in  one  district  only, 
and,  as  far  as  we  know,  be  unobserved  in  the  others. 

We  are  indebted  to  Major  Ronald  Ross,  I. M.S.,  for  extending 
and  systematising  our  knowledge  of  the  disease.  In  his  masterly 
report  upon   "The    Nature  of  Kala-azar"  to  the   Government  of 

VOL.  I  2  F 


434  MANUAL  OF  MEDICINE 

Lodia,  published  in  1899,  occurs  the  following  statement: 
'"That  Ka]a-azar  is  malaria]  fever  in  which  the  original  invasion 
gtadoallj  dies  out  daring  the  first  stage  of  the  disease,  leaving,  in 
the  second  stage;  an  acute  tumour  of  the  spleen  and  liver  accom- 
panied by  a  constant  secondary  or  symptomatic  fever,  and  finally 
lesoEting  in  a  cachexia  in  the  third  stage." 

Although  the  initial  symptoms  of  kala-azar,  which  pre\-ail  in 
malarial  districts,  are  almost,  if  not  quite,  identical  with  those  of 
malarial  fev^  yet  against  the  malarial  theory  of  the  nature  of  the 
malady  the  folowing  points  have  to  be  considered  : — the  existence 
of  a  low  constant  fever  not  amenable  to  quinine,  and  totally  unlike 
malarial  f&FSX  in  the  second  stage  of  the  disease  :  the  apparent 
absence  of  the  parasites  and  melanin  of  paludism,  both  during  life 
and  aftar  death,  from  many  established  cases  of  the  disease  ;  the 
communicability  of  kala-azar  from  the  sick  to  the  healthy ;  its 
epidemicity  and  its  hi^  death-rate. 
.  The  eridaoce  derived  firom  post-mortem  examinations  points  to 
death  by  typical  paludism,  as  far  as  the  liver,  spleen,  and  kidneys 
are  concerned.  The  structure  of  these  organs  is  practically 
unaltoed,  there  being  no  neoplasms  or  necrotic  areas.  Melanin, 
however,  is  absent  or  in  minute  quantity.  Yellow  pigment  prevails, 
but  that  is  ftequaady  due  to  a  variety  of  agencies. 

SymptoiEn&  .firsf  stage. — Kala-azar  is  ushered  in  by  a 
marked  rigoar  and  fever  of  a  severe  nature.  The  fever  at  first  is 
remittent  in  nature  but  soon  becomes  intermittent  ;  and,  in  the 
majcHrity  of  cases,  rigors  usher  in  the  recurrent  accessions.  After 
the  initial  fever,  which  lasts  fi-om  ten  days  to  twenty-one  days,  a 
period  of  apyresia  usually  supervenes,  which  may  continue  for 
weeks  or  months,  when  a  succession  of  relapses  may  occur,  the 
fever  in  each  case  resembling  the  initial,  except  that  there  may  be 
no  rigors.  On  the  othar  hand,  a  continued  low  fever  is  established 
in  many  cas^;  soon  aiier  the  jaimary  attack,  and  continues  through- 
out the  period  <^  infection. 

Enlargement  of  the  spleen  and  liver  are  met  with  from  almost 
the  first  onset  of  the  fever.  The  spleen  is  tender  to  palpation, 
and  qtdckfy  inoreases  in  size.  Anaemia  and  even  emaciation  may 
appear  during  tibe  first  stage  so  rsqiid  is  the  blood  change,  and  it  is 
this  quickly  supervening  anaemia  which  gives  rise  to  the  dark 
leaden  appearance  rf  the  features  and  skin,  which  serves  to  give 
die  name  to  the  disease — "  kala  "  signifying  black  or  deadly. 

The  second  stage. — When  the  fever  assumes  a  constant  low 
type  and  the  spleen  enlargement  is  established,  the  second  stage  of 


KALA-A2AR  435 

the  disease  is  said  to  commence.  In  regard  to  the  temperature  the 
diurnal  cur\"e  remains  the  same  day  after  day  for  weeks  or  even 
months.  If  between  96'  and  99'  one  day,  the  temperature  chart 
on  succeeding  days,  for  weeks  or  months,  will  show  the  same ;  or 
should  the  range  be  between  98''  and  102',  the  same  obtains,  show- 
ing but  a  small  range  of  variation.  The  splenic  dulness  may 
occupy  most  of  the  left  half  of  the  abdomen,  and  the  Hver  exceeds 
its  normal  limit  downwards  by  from  2  to  3  inches.  On  percussion 
both  organs  exhibit  signs  of  tenderness.  Anaemia  is  pronounced, 
but  not  excessive,  during  the  second  stage  of  the  fever.  Emaciation 
is  usual ;  and  epistaxis,  ascites,  oedema  of  the  feet,  and  sometimes 
of  the  face,  are  commonly  met  with,  and  a  slight  degree  of  icterus 
is  frequently  noted. 

Third  stage. — WTien  the  abdominal  organs  lose  their  tenderness, 
when  their  enlargement  ceases  and  fever  declines,  the  third  stage  is 
said  to  commence.  Cachexia  is  the  marked  symptom  of  this  period. 
Ascites  and  occasionally  oedema  of  the  feet  continue,  and  diarrhcea, 
dysentery,  and  pneumonia  are  wont  to  supervene.  The  patient  may 
succumb  to  asthenia,  or  he  might  recover ;  but  when  cachexia  is 
once  firmly  established  recovery  would  seem  to  be  impossible. 

The  duration  of  the  &st  stage  is  usually  from  one  to  two 
months,  and  the  beginning  of  the  third  stage  occurs  nine  months  or 
more  after  the  commencement  of  the  illness. 

Diagnosis. — Kala-azar  can  only  be  diagnosed  when  it  has 
reached  the  second  stage  of  its  course.  Before  this  period  is 
reached  ordinary  paludism,  beri-beri,  and  the  anaemic  state  resulting 
from  ankylostomiasis,  have  all  been  mistaken  for  it. 

Prognosis. — "  The  death-rate  is  high,  but  recovery  often 
occurs  "  (Ross).  Death  takes  place  occasionally  during  the  second 
stage  of  the  disease,  but  it  is  the  third  stage  during  which  marked 
fatality  occurs. 

Treatment. — Most  observers  maintain  that  quinine  is  not  only 
useless,  but  even  harmful  in  kala-azar.  The  first  dut)'  of  the 
practitioner  is  to  examine  the  stools  for  the  ova  of  the  ankylostoma 
and,  if  present,  administer  the  appropriate  remedies  for  their  expulsion. 
This  step  is  taken  not  in  the  belief  that  the  ankylostoma  are  the 
cause  of  the  disease,  but  in  order  to  remove  the  lowering  tendency 
a  number  of  intestinal  parasites  have  on  the  general  health.  Further 
treatment  consists  in  maintaining  the  patient's  strength,  counter- 
acting the  anaemia,  relieving  the  ascites,  and  obtaining,  if  possible,  a 
change  of  air. 

James  Cantlie. 


INDEX 


Actinomycosis,  244 

diagnosis,  248 

histology,  245 

symptoms,  246 

treatment,  248 
Anthrax,  152 

bacteriology,  152 

diagnosis,  154 

post-mortem  appearances,  155 

prognosis,  155 

symptoms,  153 

treatment,  156 
Antitoxin,  44 

cholera,  124 

diphtheria,  177 

erysipelas,  67 

plague,  137 

tetanus,  161 

typhoid,  106 
Aspergillar  mycosis,  249 
Atmospheric  pressure,   variations  of,   ; 
causing  disease,  15 

diminished  pressure — symptoms,  19 

increased  pressure,  16 
pathology  of,  18 
post-mortem  appearances  in,  18 
symptoms  of,  17 
treatment  of,  18 

Bacteria,  characters  of,  25 

cultivation  of,  28 

parasitism  of,  27 

spore  formation,  26 

structure  of,  26 

toxic  products  of,  29 
Beri-beri,  353 

atrophic  form,  356 

diagnosis,  359 

etiology,  353 

heart  s-ffections  in,  358 


Beri-beri,  incubation  period,  354 

mixed  form,  357 

motor  disturbances,  357 

cedematous  form,  358 

post-mortem  appearances,  358 

prognosis,  358 

symptoms,  354 

treatment,  359 
Blackwater  fever.     See  Haemoglobinuric 

Fever,  429 
Boil,  59 

etiology  of,  59 

pathology  of,  59 

symptoms  of,  60 

treatment  of,  61 
Break  bone  fever.      See  Dengue,  350 

Caisson  disease,  16 

Calmette's  anti-plague  serum,  139 

Carbuncle,  59 

etiology  of,  59 

pathology  of,  59 

symptoms,  60 

treatment,  61 
Cerebro  -  spinal    fever.        See     Epidemic 

Cerebro-spinal  Meningitis,  182 
Chicken-pox,  310 

bacteriology,  314 

complications,  314 

diagnosis,  315 

incubation,  310 

symptoms,  311 

treatment,  315 
Cholera,  116 

anti- choleraic  inoculations,  121 

bacteriology  of,  118 

diagnosis,  122 

etiology,   117 

geographical  distribution,  116 

incubation,  period  of,   120 


438 


MANUAL  OF  MEDICINE 


Cholera,  mortality  of,  123 

post-mortem  appearances  in,  123 

prognosis,  123 

sequelae,  122 

symptoms,  120 

treatment,  124 
Cold,  morbid  conditions  due  to,  14 

treatment  of,  15 
Coley's  fluid,  66 
Cow-pox,  328 
Crescent  bodies  in  malaria,  420 

Delhi  boil.     See  Oriental  Sore,  362 
Dengue,  350 

diagnosis,  352 

geographical  distribution,  350 

incubation,  350 

prognosis,  352 

sequelafe,  351 

symptoms,  350 

treatment,  352 

varieties,  351 
Diazobenzol  reaction  of  the  urine,  94 
Diphtheria,  163 

bacteriology,  174 

complications,  170 

diagnosis,  176 

etiology,  163 

incubation  period,  165 

post-mortem  appearances,  176 

prognosis,  172 

symptoms,  166 

treatment,  177 
Diseases   excited   by  atmospheric    influ- 
ences, 10 
Dysentery,  402 

chronic,  407 

diagnosis,  410 

etiology,  402 

liver  abscess  in,  408 

parasitology,  404 

post-mortem  appearances,  409 

prognosis,  411 

symptoms,  405 

treatment,  412 

varieties  of,  406 

Ehrlich's  test,  94 

Electricity,  morbid  conditions  due  to,  21 

pathology  of,  22 

post-mortem  appearances,  22 

symptoms  of,  21 

treatment  of,  23 
Endemic  disease,  47 
Enteric  fever.     See  Typhoid  Fever,  86 


Epidemic  cerebro-spinal  meningitis,  182 

bacteriology,  186 

complications,  184 

diagnosis,  187 

post-mortem  appearances,  185 

prognosis,  186 

symptoms,  183 

treatment,  187 
Epidemic  disease,  48 
Epidemic  dropsy,  360 

diagnosis,  361 

etiology,  360 

geographical  distribution,  360 

symptoms,  361 

treatment,  361 
Epidemic  pneumonia,  178 
Erysipelas,  64 

bacteriology  of,  63 

etiology,  64 

pathology,  62 

symptoms,  65 

treatment,  67 

Famine  fever.     See  Relapsing  Fever,  139 
Farcy.     See  Glanders,  217 

buds,  218 
Fever,  symptoms  of,  50 
Foot  and  mouth  disease,  396 

diagnosis,  398 

symptoms,  397 

treatment,  398 
FrambcEsia,  365 

symptoms,  366 

treatment,.  366 
Frostbite,  15 

General  diseases — definition  and  classifi- 
cation of,  9 
German  measles.     See  Rotheln,  269 
Glanders,  217 
bacteriology,  217 
diagnosis,  219 
symptoms,  218 
treatment,  219 
Gonorrhoeal  infection,  82 
arthritis,  82 

diagnosis  of,  84 
symptoms  of,  83 
treatment,  85 

Haemoglobinuric  fever,  429 
diagnosis,  431 
etiology,  429 
pathology,  431 
prognosis,  432 
symptoms,  430 
treatment,  432 


f  INDEX 


439 


Haffkine's  anti-cholera  vaccine,  124 

anti-plague  fluid,  137 
Heat-apoplexy,  11 

morbid  conditions  due  to,  10 
pathology  of,  13 
post-mortem  appearances,  12 
Heat-stroke,  cause  and  symptoms,  10 
sequelae,  12 
treatment,  13 
Hydrophobia.     See  Rabies,  389 
Hyperpyrexia,   post-mortem  appearances 
of,  S7 
treatment  of,  57 

Immunity,  35 

active,  39 

passive,  38 
Infections,  the,  24 

classification  of,  47 

general  course  and  characters  of,   45, 
398 

post-mortem  appearances  in,  47 

terminations  of,  46 
Infective  endocarditis,  77 

clinical  varieties  of,  80 

diagnosis,  81 

pathology   and    post-mortem    appear- 
ances, 77 

symptoms,  79 

treatment,  81 
Infective  meningitis,  182 
Infective  roseola,  273 
Influenza,  202 

abdominal  type,  204 

bacteriology,  212 

complications,  204 

course,  204 

diagnosis,  208 

etiology,  211 

post-mortem  appearances,  211 

prognosis,  213 

pulmonary  type,  203 

sequelae,  204 

simple  type,  202 

special  symptoms,  204 

treatment,  214 

Kala-azar,  433 

diagnosis,  435 

etiology,  433 

prognosis,  435 

symptoms,  434 

treatment,  435 
Kernig's  sign,  184 

Leprosy,  235 


Leprosy,  bacteriology,  237 

diagnosis,  241 

etiology,  236 

geographical  distribution,  235 

incubation  period,  238 

prognosis,  241 

symptoins,  238 

treatment,  242 

varieties,  238 
Liver  abscess  in  dysentery,  408 
Lockjaw.      See  Tetanus,  158 
Lyssophobia,  394 

Madura  foot,  249 
Malaria,  416 

clinical  characters,  422 

effects  of,  424 

etiology,  416 

parasites  of,  417 

post-mortem  appearances,  425 

prognosis,  425 

prophylaxis,  426 

treatment,  426 

varieties  of,  424-426 
Malignant  pustule.      See  Anthrax,  152 
Malta  fever.  5^^  Mediterranean  Fever,  110 
Measles,  259 

bacteriology,  266 

complications,  264 

diagnosis,  267 

etiology,  259 

prognosis,  266 

symptoms,  263 

treatment,  268 
Mediterranean  fever,  no 

diagnosis  of,  114 

etiology  of,  in 

geographical  distribution,  no 

morbid  anatomy,  114 

prognosis,  114 

prophylaxis,  114 

symptoms,  in 

temperature  charts  in,  114 

treatment,  115 
Membranous  croup.    See  Diphtheria,  163 
Mixed  infections,  398 

frequency  of  occurrence,  399 
Mosquito,  relation  to  malaria,  420 
Mountain  sickness,  19 
Mumps,  337 

complications,  339 

diagnosis,  340 

etiology,  337 

incubation  period,  338 

prognosis,  340 

symptoms,  338 


440 


MANUAL  OF  MEDICINE 


Mumps,  treatment,  340 
Mycetoma,  249 
Mycoses,  243 

Oriental  sore,  362 
etiology,  362 

geographical  distribution,  362 
prognosis,  363 
symptoms,  363 
treatment,  363 

Pertussis.     See  Whooping-Cough,   340 
Phagocytosis,  34 
Plague,  128 

bacteriology,  129 

communicability,  130 

diagnosis,  134 

etiology,  129 

geographical  distribution,  128 

Haffkine's  anti-plague  fluid,  137 

morbid  anatomy,  135 

mortality,  137 

prognosis,  136 

prophylaxis,  137 

symptoms,  131 

treatment,  138 

variations  in  type,  132 
Posterior  basic  meningitis,  189 

bacteriology,  190 

complications,  192 

diagnosis,  194 

etiology,  189 

post-mortem  appearances,  195 

prognosis,  193 

symptoms,  190 

treatment,  195 
Predisposition,  39 
Ptomaines,  31 
Pyaemia,  nature  of,  74 

post-mortem  appearances,  75 

symptoms,  76 

treatment,  78 
Pyrexia,  50 

excretion  of  COg  and  N  in,  56 

occurrence  in  various  diseases,  52 

post-mortem  appearances  of,  57 

production  of,  51 

treatment,  57 

Rabies,  389 
diagnosis,  393 
"  dumb  rabies,"  392 
incubation  period,  391 
mode  of  infection,  390 
morbid  anatomy,  393 
symptoms,  391 


Rabies,  treatment,  395 

virus,  390 
Relapsing  fever,  139 

diagnosis,  142 

pathology,  141 

post-mortem  appearances,  142 

prognosis,  142 

symptoms,  140 

treatment,  142 
Resistance  of  the  tissues,  33 
Rheumatic  fever,  291 

nodules,  294 
Rheumatism,  acute  and  subacute,  291 

chorea  in,  296 

cutaneous  manifestations  in,  295 

heart  affections  in,  291 

joints  in,  294 

pathology,  302 

prognosis,  304 

tonsillitis  in,  295 

treatment,  306 

urine  in,  295 
Rotheln,  269 

diagnosis,  272 

symptoms,  270 

treatment,  272 

Sapraemia,  nature  of,  69 

symptoms,  71 

treatment,  73 
Scarlet  fever,  274 

bacteriology,  287 

complications,  286 

diagnosis,  288 

etiology,  274 

incubation,  276 

post-mortem  appearances,  287 

prognosis,  288 

septic  form,  282 

simple  form,  276 

toxic  form,  284 

treatment,  288 
Septicaemia,  nature  of,  72 

diagnosis,  73 

post-mortem  appearances,  73 

treatment,  74 
Serum  diagnosis,  32,  102 
Siriasis,  11 
Smallpox,  316 

complications,  321 

diagnosis,  324 

histology,  323 

incubation,  317 

inoculation  for,  327 

mode  of  conveyance,  316 

modified,  323 


INDEX 


441 


Smallpox,  prodromal  rashes,  319 
seasonal  prevalence,  316 
symptoms,  318 
treatment,  325 
Splenic  fever.      See  Anthrax,  152 
Subcutaneous  nodules  in  rheumatic  fever, 

294 
Suppurative  meningitis,  196 
bacteriology,  197 
diagnosis,  199 
etiology,  197 

post-mortem  appearances,  200 
prognosis,  199 
sjTnptoms,  198 
treatment,  201 
Syphilis,  367 

acquired  in  adults,  367 
acquired  in  infants,  386 
diagnosis,  372,  386 
prognosis,  373 
symptoms,  368 
treatment,  373 
inherited,  374 
Colles's  law,  377 
effect  on  mother,  376 
prognosis,  387 
symptoms,  378 
treatment,  387 

Tache  bleuatre,  93 
Temperature,  normal,  50 
Tetanus,  156 

bacteriology,  156 

diagnosis,  160 

etiology,  158 

incubation,  158 

ner\-atorum,  158 

post-mortem  appearances,  160 

prognosis,  160 

symptoms,  158 

treatment,  161 
Thermic  fever,  11 
Trismus.      See  Tetanus,  158 
Tuberculosis,  220 

bacteriology,  220 

contagiousness,  231 

curability,  232 

distribution  in  various  organs,  223 

duration  of,  234 

histology,  221 

influence  of  age  and  sex,  230 

invasion,  223 

symptoms,  232 

treatment,  234 
Typhoid  fever,  86 

bacteriolog}'  of,  86 


T)'phoid  fever,  cold  baths  in,  107 

complications  of,  96 

diagnosis  of,  102 

diet  in,  106 

etiology  of,  87 

incubation  of,  92 

onset  of,  90 

post-mortem  appearances  in,  90 

preveritive  inoculation  in,  106 

prognosis,  104 

prophylaxis,  105 

rash  in,  93 

relapses  in,  loi 

sequelae,  96 

stools,  disposal  of,  105 

s}anptoms,  92 

treatment,  106 

varieties  of,  95 

without  intestinal  lesions,  87 
"  Typhoid  state,"  95 
Typhus  fever,  252 

bacteriolog}',  252 

complications,  256 

diagnosis,  256 

etiolog}-,  252 

morbid  anatomy,  253 

symptoms,  253 

treatment,  257 

Vaccination,  39,  328 

alleged  injurious  effects  of,  333 

glycerinated  lymph,  335 

history'  of,  331 

practice  of,  335 

protection  afforded  by,  332 

revaccination,  333 
Vaccinia,  328 

histologj',  330 

relation  to  variola,  329 
Varicella.     See  Chicken-pox,  310 

bullosa,  314 

gangrenosa,  314 
Variola.      See  Smallpox,  316 
Varioloid,  323 
Verruga  peruana,  364 

diagnosis,  365 

symptoms,  364 

treatment,  365 

WTiooping-cough,  340 
bacteriology,  340 
clinical  course,  342 
complications,  345 
convalescence,  346 
diagnosis,  347 
paroxysmal  stage,  343 


442 


MANUAL  OF  MEDICINE 


Whooping-cough,  prodromal  stage,  342 

prognosis,  347 

treatment,  348 
Widal's  serum  reaction,  32,  102 
Woolsorters'  disease.     See  Anthrax,  153 

Yaws.     See  Frambcesia,  365 
Yellow  fever,  143 
bacteriology,  144 


Yellow  fever,  diagnosis,  146 

morbid  anatomy,  147 

prognosis,    [46 

seasonal  prevalence,  143 

symptoms,  144 

treatment,  147 
Yersin's  anti-plague  serum,  139 

Zenker's  vitreous  degeneration,  91,  253 


END    OF    VOL.    I 


MACMILLAN'S  MANUALS  OF  MEDICINE  AND  SURGERY 


A  MANUAL  OF  SURGERY 

By  CHARLES   STONHAM 

Senior  Surgeon  to  the  Westminster  Hospital 

Fully  Illustrated.        Three  Volumes.        Cloth.        i2mo.        $6.00  net 


Volume      I.  —  General  Surgery 

Volume    II.  —  Injuries 

Volume  III. — Regional  Surgery 

A  succinct  account  of  modern  surgical  pathology,  diagnosis  and 
treatment  — A  manual  for  practitioners  and  students  —  The  results  of 
sixteen  years'  experience  as  a  hospital  surgeon  and  teacher. 


INTRODUCTION   TO 

The  Outlines  of   the  Principles  of    Differential 

Diagnosis 

WITH  CLINICAL  MEMORANDA 
By  FRED  J.   SMITH,  M.D. 

Physician  {with  care  of  out-patients)  and  Senior  Pathologist  to  the  London  Hospital 

Cloth.        Extra  Crown.        8vo.        $2.00  net 


CONTENTS: 

I.  Introduction  —  Steps  in  Diagnosis  —  Causes  of  Disease 

II.  Physical  Signs  v.  Symptoms  —  Pathology  —  Contagion  v.  Infection 

III.  Micro-organisms  and  Disease 

IV.  Diseases  of  Thoracic  Organs 

IV.  [continued].    Heart  and  Pericardium 

V.  Diseases  of  Nose,  Throat,  and  Alimentary  System 

VI.  Diseases  of  the  Urinary  Organs 

VII.  Affections  of  Joints 

VIII.  Anatomy  and  Physiology  of  the  Nervous  System 

IX.  Urgency  Cases  —  Haemorrhage  —  Other  Vascular  Lesions 


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SYSTEM    OF 

MEDICINE  AND  GYNAECOLOGY 

BV  MORE    THAN  TWO  HUNDRED  EMINENT  AUTHORITIES 

Edited  by  THOMAS   CLIFFORD  ALLBUTT 

University  of  Cambridge 
WITH   THE   CO-EDITORSHIP   ON   GYN.ECOLOGY   OF 

WILLIAM  SMOULT  PLAYFAIR 

Kijig's  College 


Complete  in  nine  volumes  of  about  i,ooo   pages   each,  with   many 

charts,  plates,  tables,  diagrams,  etc.,  both  in  black  and  in  colors. 

Price  per  volume,  Cloth,  $5.00  ;  Sheep,  $6.00  ;   Half  Morocco,  $6.50  net 


CONTENTS    OF   VOLUMES: 

Volume  I.  —  Prolegomena.    Fevers. 

Volume  II.  —  Infective  Dise.\ses.  Diseases  of  Uncertain  Bacteriology. 
Diseases  Due  to  Protozoa.    Intoxications.     Internal  Parasites. 

Volume  III.  —  Diseases  of  Obscure  Causation.  Alimentation  and  Excre- 
tion.   ST01LA.CH,  Peritoneum,  Bo\\"els. 

Volume  IV.  —  Diseases  of  Lfver,  Kidneys,  L\'iipiLA.Tics.  Ductless  Glands, 
Respiratory  Organs.    Nose,  Pharynx,  Larynx. 

VOLL"ME   V.  —  DISKA.SES  OF  RESPIR.A.T0RY  ORGANS.      PlEURA,  CIRCUL.\T0RY  SySTEM. 

Volume  VI.  —  Diseases  of  Circulatory  System.  Muscles,  Nervous  System, 
Nerves,  Spine. 

VoLUifE  VII.  —  Diseases  of  Nervous  System.  Spinal  Cord,  Br.\in.  Other 
Diseases  of  Nervous  System. 

VoLLiiE  VIII. —  Mental  Diseases.     Skin  Diseases. 

Voll^ie  IX.  —  Gynecology.     Medical  and  Surgical. 


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